=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720742729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVAN HORACIO VEGA FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2021
-----------------------------------------------------
Last Update Date | 10/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E. 24TH ST SUITE 3A
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-750-6410
-----------------------------------------------------
Fax | 928-750-6433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 617
-----------------------------------------------------
City | SOMERTON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85350-0617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-315-7910
-----------------------------------------------------
Fax | 928-722-6113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WE0003X
-----------------------------------------------------
Taxonomy Name | Emergency Registered Nurse
-----------------------------------------------------
License Number | RN185788
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 268101
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------