Provider Demographics
NPI:1316143472
Name:VERGILIS, MARINA (PA-C)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:VERGILIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18370 BURBANK BLVD
Mailing Address - Street 2:SUITE 407
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2804
Mailing Address - Country:US
Mailing Address - Phone:818-996-4242
Mailing Address - Fax:818-996-4352
Practice Address - Street 1:13326 MAXELLA AVE
Practice Address - Street 2:UNIT 3
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5639
Practice Address - Country:US
Practice Address - Phone:310-593-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2009-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18548363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical