Provider Demographics
NPI:1184961435
Name:VEGA, KIRSTYN LEE (PA-C)
Entity type:Individual
Prefix:
First Name:KIRSTYN
Middle Name:LEE
Last Name:VEGA
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 1:820 SPRINGER DR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6413
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:
Practice Address - Street 1:10512 PARK RD
Practice Address - Street 2:SUITE 113
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8475
Practice Address - Country:US
Practice Address - Phone:704-542-8018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant