Healthcare Provider Details

I. General information

NPI: 1841479839
Provider Name (Legal Business Name): CARLOS VASQUEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4067 TWEEDY BLVD
SOUTH GATE CA
90280-6146
US

IV. Provider business mailing address

4067 TWEEDY BLVD
SOUTH GATE CA
90280-6146
US

V. Phone/Fax

Practice location:
  • Phone: 323-569-1126
  • Fax: 877-403-7113
Mailing address:
  • Phone: 323-569-1126
  • Fax: 877-403-7113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14141
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: