Healthcare Provider Details

I. General information

NPI: 1891380317
Provider Name (Legal Business Name): JASMIN VASQUEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JASMIN BETANCOURT

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 12/07/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9930 W INDIAN SCHOOL RD
PHOENIX AZ
85037-5902
US

IV. Provider business mailing address

530 N THOMAS RD
PHOENIX AZ
85012-3204
US

V. Phone/Fax

Practice location:
  • Phone: 623-846-7558
  • Fax:
Mailing address:
  • Phone: 602-422-9000
  • Fax: 602-556-5951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8850
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: