Healthcare Provider Details

I. General information

NPI: 1558184812
Provider Name (Legal Business Name): VANESSA PEREZ MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 PROFESSIONAL DR
SANTA ROSA CA
95403-3007
US

IV. Provider business mailing address

963 MADRONE RD # ATPB6
GLEN ELLEN CA
95442-9686
US

V. Phone/Fax

Practice location:
  • Phone: 707-544-3295
  • Fax:
Mailing address:
  • Phone: 707-890-2205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: