Provider Demographics
NPI:1336782028
Name:VEGA, RAUL LAZARO (PTA)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:LAZARO
Last Name:VEGA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11630 W RIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7452
Mailing Address - Country:US
Mailing Address - Phone:786-301-9745
Mailing Address - Fax:
Practice Address - Street 1:803 OAK ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-4317
Practice Address - Country:US
Practice Address - Phone:904-284-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29739225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant