Provider Demographics
NPI:1194097147
Name:QUAN VEGA, MAIN YIE (PHD)
Entity type:Individual
Prefix:DR
First Name:MAIN
Middle Name:YIE
Last Name:QUAN VEGA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 203
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:SD
Mailing Address - Zip Code:57719-0203
Mailing Address - Country:US
Mailing Address - Phone:605-867-3162
Mailing Address - Fax:
Practice Address - Street 1:3409 AVE ISLA VERDE APT 1103
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979-4903
Practice Address - Country:US
Practice Address - Phone:787-923-3708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11845103TC0700X
PR3284103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical