MEDICARE: VANESSA A ACOSTA PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant
2	363A00000X	Physician Assistant	PA2020-0112	NM

General Provider Information

NPI Number	:	1700482478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA A ACOSTA PA

Provider Business Mailing Address
First Line	:	601 MENAUL BLVD NE UNIT 2501
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-1553
Country	:	US
Telephone Number	:	505-544-7508
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 MORNINGSIDE DR SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-2633
Country	:	US
Telephone Number	:	505-266-0888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2020
Last Update Date	:	10/08/2024

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Directions to “ VANESSA A ACOSTA PA” Practice Location

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