Healthcare Provider Details

I. General information

NPI: 1467380303
Provider Name (Legal Business Name): VIB PHYSICIAN ASSISTANT PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S DELAWARE ST
SAN MATEO CA
94402-2150
US

IV. Provider business mailing address

1506 S DELAWARE ST
SAN MATEO CA
94402-2150
US

V. Phone/Fax

Practice location:
  • Phone: 650-464-3997
  • Fax:
Mailing address:
  • Phone: 650-464-3997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: VADIM BEDEROV
Title or Position: OWNER
Credential: PA
Phone: 650-464-3997