Provider Demographics
NPI:1982977096
Name:BERRIOS, VANESSA M (PA-C)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:M
Last Name:BERRIOS
Suffix:
Gender:F
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:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:30 ARDISIA LANE
Practice Address - Street 2:
Practice Address - City:ST. JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:904-287-2794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111696363AM0700X, 363A00000X
NC0010-03371363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC58280322Medicare PIN