Provider Demographics
NPI:1386517761
Name:VAZQUEZ, EDWIN
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E WARWICK DR
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1010
Mailing Address - Country:US
Mailing Address - Phone:989-463-2779
Mailing Address - Fax:989-463-2064
Practice Address - Street 1:120 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1010
Practice Address - Country:US
Practice Address - Phone:989-463-2779
Practice Address - Fax:989-463-2064
Is Sole Proprietor?:No
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704311697363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health