MEDICARE: SUSAN L VASQUEZ PAC

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	PA17686	CA
2	363A00000X	Physician Assistant	1063898	CA

General Provider Information

NPI Number	:	1548429699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN L VASQUEZ PAC

Provider Business Mailing Address
First Line	:	PO BOX 307
Second Line	:
City	:	COVINA
State	:	CA
Zip	:	91723-0307
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1568 N ORANGE GROVE AVE
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91767-3812
Country	:	US
Telephone Number	:	909-868-6666
Fax Number	:

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

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	10/13/2010

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Directions to “ SUSAN L VASQUEZ PAC” Practice Location

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