Provider Demographics
NPI:1063078897
Name:MANOSALVA VARGAS, LAURA MONICA (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MONICA
Last Name:MANOSALVA VARGAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MONICA
Other - Last Name:VARGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4175 W BROADWAY APT C
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-4097
Mailing Address - Country:US
Mailing Address - Phone:561-213-2902
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:BLDG.500, NSGY SUITE 6664
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56793363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical