Provider Demographics
NPI:1861496440
Name:BECKER, VANESSA N (PA-C)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:N
Last Name:BECKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 E EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4414
Mailing Address - Country:US
Mailing Address - Phone:210-271-0606
Mailing Address - Fax:210-475-9806
Practice Address - Street 1:520 E EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4414
Practice Address - Country:US
Practice Address - Phone:210-271-0606
Practice Address - Fax:210-475-9806
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOORM40OtherMEDICARE GROUP PTAN