Provider Demographics
NPI:1700292851
Name:VEGA, ANDRES (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
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 1:916-922 MAIN AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-8544
Mailing Address - Country:US
Mailing Address - Phone:973-773-0334
Mailing Address - Fax:973-773-0336
Practice Address - Street 1:916-922 MAIN AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055
Practice Address - Country:US
Practice Address - Phone:973-773-0334
Practice Address - Fax:973-773-0336
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00336400207R00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1639427495OtherGROUP NPI