Provider Demographics
NPI:1881358026
Name:MONTES, VIVIAN
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:MONTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 VALPREDA RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 VALPREDA RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2973
Practice Address - Country:US
Practice Address - Phone:760-736-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA62019363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant