Healthcare Provider Details

I. General information

NPI: 1104310267
Provider Name (Legal Business Name): ENRIQUE XAVIER VACA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S HERCULES AVE STE 102
CLEARWATER FL
33764-6320
US

IV. Provider business mailing address

13324 FAWN LILY DR
RIVERVIEW FL
33579-0010
US

V. Phone/Fax

Practice location:
  • Phone: 727-442-6068
  • Fax:
Mailing address:
  • Phone: 786-382-6911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110684
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: