Provider Demographics
NPI:1386946770
Name:VEGA, RICARDO (PA)
Entity type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3606
Mailing Address - Country:US
Mailing Address - Phone:213-749-6500
Mailing Address - Fax:213-749-7465
Practice Address - Street 1:115 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3606
Practice Address - Country:US
Practice Address - Phone:213-749-6500
Practice Address - Fax:213-749-7465
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant