Provider Demographics
NPI:1942980164
Name:BRISENO, VANESSA PENA (PA-C)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:PENA
Last Name:BRISENO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 W PINE HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-9341
Mailing Address - Country:US
Mailing Address - Phone:209-855-1704
Mailing Address - Fax:
Practice Address - Street 1:3300 WEBSTER ST STE OAKLAND
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3117
Practice Address - Country:US
Practice Address - Phone:510-452-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant