Provider Demographics
NPI:1174282586
Name:VAQUERA, JACQUELINE PAIGE (PA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:PAIGE
Last Name:VAQUERA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-6674
Mailing Address - Fax:336-716-9188
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1811
Practice Address - Country:US
Practice Address - Phone:336-716-6674
Practice Address - Fax:336-716-9188
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010579363A00000X
NC00010-15496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant