Healthcare Provider Details

I. General information

NPI: 1114173978
Provider Name (Legal Business Name): VANESSA M RODRIGUEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E 86TH CT
MERRILLVILLE IN
46410-6259
US

IV. Provider business mailing address

205 E 86TH CT
MERRILLVILLE IN
46410-6259
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-9070
  • Fax: 219-769-1758
Mailing address:
  • Phone: 219-769-9070
  • Fax: 219-769-1758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001486A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: