Healthcare Provider Details

I. General information

NPI: 1881967818
Provider Name (Legal Business Name): JOLENE LEEANN VIGIL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

933 BRADBURY DR SE
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-6366
  • Fax: 714-456-8017
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2012-0005
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: