Provider Demographics
NPI:1841513314
Name:VEGA, AMY ELIZABETH MOON (CRNA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH MOON
Last Name:VEGA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:E
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-628-6990
Practice Address - Fax:804-628-6932
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168665367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1841513314Medicaid
VAQ36723GMedicare UPIN