MEDICARE: MRS. STACEY VASQUEZ 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	54832	CA

General Provider Information

NPI Number	:	1942728795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACEY VASQUEZ PA-C

Provider Business Mailing Address
First Line	:	PO BOX 532
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92842-0532
Country	:	US
Telephone Number	:	714-679-3013
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311 S ANAHEIM BLVD
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92805-6202
Country	:	US
Telephone Number	:	714-635-6400
Fax Number	:

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

Provider Enumeration Date	:	08/31/2017
Last Update Date	:	12/03/2021

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