Healthcare Provider Details

I. General information

NPI: 1376766741
Provider Name (Legal Business Name): VANESSA LAZARO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6195 LUSK BLVD STE 250
SAN DIEGO CA
92121-3715
US

IV. Provider business mailing address

6195 LUSK BLVD STE 250
SAN DIEGO CA
92121-3715
US

V. Phone/Fax

Practice location:
  • Phone: 858-859-1188
  • Fax: 844-404-8924
Mailing address:
  • Phone: 858-859-1188
  • Fax: 844-404-8924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18249
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number18249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: