Provider Demographics
NPI:1902242480
Name:FUENTES, VANESSA JIMENEZ (PA-C)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:JIMENEZ
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 NANCE RD
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9605
Mailing Address - Country:US
Mailing Address - Phone:760-679-6259
Mailing Address - Fax:
Practice Address - Street 1:251 W COLE BLVD
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-9722
Practice Address - Country:US
Practice Address - Phone:760-357-3768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA23016OtherLICENSE