MEDICARE: DEIDRE VAUGHN 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	363A00000X	Physician Assistant	PA5692	MA
2	363A00000X	Physician Assistant	PA65505	CA
3	363AS0400X	Surgical Physician Assistant		MA

General Provider Information

NPI Number	:	1437519931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIDRE VAUGHN PA-C

Provider Business Mailing Address
First Line	:	41 MALL RD
Second Line	:	NEUROSURGERY DEPT
City	:	BURLINGTON
State	:	MA
Zip	:	01805-0001
Country	:	US
Telephone Number	:	781-744-7580
Fax Number	:	781-744-5778

Provider Business Practice Location Address
First Line	:	525 DOYLE PARK DR STE 102
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4562
Country	:	US
Telephone Number	:	707-387-3922
Fax Number	:	707-523-0679

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

Provider Enumeration Date	:	02/26/2016
Last Update Date	:	12/08/2025

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Directions to “ DEIDRE VAUGHN PA-C” Practice Location

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