Healthcare Provider Details

I. General information

NPI: 1053225110
Provider Name (Legal Business Name): VANESSA I MARES ANDRADE PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 CLUB DR
VALLEJO CA
94592-1187
US

IV. Provider business mailing address

2655 STEPHANIE ST
SELMA CA
93662-4906
US

V. Phone/Fax

Practice location:
  • Phone: 707-638-5809
  • Fax:
Mailing address:
  • Phone: 559-819-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: