Provider Demographics
NPI:1265257026
Name:VERGARA, RONALD JAMES TUPAZ
Entity type:Individual
Prefix:
First Name:RONALD JAMES
Middle Name:TUPAZ
Last Name:VERGARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 MERCHANT ST STE A
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-5315
Mailing Address - Country:US
Mailing Address - Phone:707-234-5224
Mailing Address - Fax:
Practice Address - Street 1:941 MERCHANT ST STE A
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-5315
Practice Address - Country:US
Practice Address - Phone:707-234-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95033008363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health