Provider Demographics
NPI:1205569639
Name:VEGA, VICTORIA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ROSE
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 1:478 FILMORE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3811
Mailing Address - Country:US
Mailing Address - Phone:859-321-9421
Mailing Address - Fax:
Practice Address - Street 1:402 6TH ST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1619
Practice Address - Country:US
Practice Address - Phone:208-650-7941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-04
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical