Provider Demographics
NPI:1669407243
Name:DORSEY, VINCENT C (PA)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:C
Last Name:DORSEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0722
Mailing Address - Country:US
Mailing Address - Phone:909-793-3311
Mailing Address - Fax:909-796-4158
Practice Address - Street 1:7000 BOULDER AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-3348
Practice Address - Country:US
Practice Address - Phone:909-862-1191
Practice Address - Fax:909-796-4158
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13832Medicaid
CAS19481Medicare UPIN