Provider Demographics
NPI:1841479839
Name:VASQUEZ, CARLOS (PA)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:VASQUEZ
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 1:17525 VENTURA BLVD
Mailing Address - Street 2:203
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3843
Mailing Address - Country:US
Mailing Address - Phone:818-986-0200
Mailing Address - Fax:818-986-4393
Practice Address - Street 1:2200 W 3RD ST
Practice Address - Street 2:#400
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1932
Practice Address - Country:US
Practice Address - Phone:213-484-7600
Practice Address - Fax:818-638-5762
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14141363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14141OtherPA LICENSE
CAS90720Medicare UPIN
CAPA14141OtherPA LICENSE