MEDICARE: GILBERT G VEGA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	3434	AZ
2	363A00000X	Physician Assistant	3434	AZ

General Provider Information

NPI Number	:	1285664151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GILBERT G VEGA PA-C

Provider Business Mailing Address
First Line	:	PO BOX 669
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85366-2329
Country	:	US
Telephone Number	:	928-342-6500
Fax Number	:	928-627-9105

Provider Business Practice Location Address
First Line	:	1962 E JUAN SANCHEZ BLVD STE C2
Second Line	:
City	:	SAN LUIS
State	:	AZ
Zip	:	85336-0478
Country	:	US
Telephone Number	:	928-627-4825
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	10/14/2021

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