Provider Demographics
NPI:1851901169
Name:CORREA-VEGA, ANDRES
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:CORREA-VEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 OAKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-1579
Mailing Address - Country:US
Mailing Address - Phone:321-900-5391
Mailing Address - Fax:
Practice Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7593
Practice Address - Country:US
Practice Address - Phone:407-970-0824
Practice Address - Fax:321-235-5506
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30303225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty