Provider Demographics
NPI:1932683034
Name:VAZQUEZ, ANDRES (CAA)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-389-2338
Mailing Address - Fax:414-385-8987
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:786-478-2093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Single Specialty