Provider Demographics
NPI:1104310267
Name:VACA, ENRIQUE XAVIER (PA-C)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:XAVIER
Last Name:VACA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13324 FAWN LILY DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-0010
Mailing Address - Country:US
Mailing Address - Phone:786-382-6911
Mailing Address - Fax:
Practice Address - Street 1:300 RIVERSIDE DR E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1008
Practice Address - Country:US
Practice Address - Phone:941-748-4847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110684363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant