Provider Demographics
NPI:1972217446
Name:VASQUEZ, VICTOR ELI (PA-C)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:ELI
Last Name:VASQUEZ
Suffix:
Gender:M
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 1:209 VICTORIA RD
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114-2800
Mailing Address - Country:US
Mailing Address - Phone:860-712-8131
Mailing Address - Fax:
Practice Address - Street 1:580 COTTAGE GROVE RD STE 107
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3088
Practice Address - Country:US
Practice Address - Phone:860-243-8709
Practice Address - Fax:860-243-8259
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5936363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical