Provider Demographics
NPI:1972050060
Name:VASHISHTA, SUZANNE (PA-C)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:VASHISHTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:22 CORPORATE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7985
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7985
Practice Address - Country:US
Practice Address - Phone:949-722-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55462363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant