Provider Demographics
NPI:1750796330
Name:VEGA GONZALEZ, DAIBELIZ TAMARA (MSPAS, PA-C, ATC)
Entity type:Individual
Prefix:
First Name:DAIBELIZ
Middle Name:TAMARA
Last Name:VEGA GONZALEZ
Suffix:
Gender:F
Credentials:MSPAS, PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:611 W FRANCIS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-0614
Mailing Address - Country:US
Mailing Address - Phone:308-568-3500
Mailing Address - Fax:
Practice Address - Street 1:611 W FRANCIS ST STE 200
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-0614
Practice Address - Country:US
Practice Address - Phone:308-568-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006419363A00000X
FL20000166082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer