Healthcare Provider Details

I. General information

NPI: 1417566514
Provider Name (Legal Business Name): CRISTINA VEGA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 E HERNDON AVE STE 230
FRESNO CA
93720-3392
US

IV. Provider business mailing address

1111 E SPRUCE AVE STE 431
FRESNO CA
93720-3330
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-2663
  • Fax: 559-450-2724
Mailing address:
  • Phone: 559-450-7449
  • Fax: 559-450-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58102
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number58102
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: