Provider Demographics
NPI:1982076287
Name:VAUGHAN, PETA (AS)
Entity type:Individual
Prefix:
First Name:PETA
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 W 4TH ST APT 201
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-2187
Mailing Address - Country:US
Mailing Address - Phone:805-905-1785
Mailing Address - Fax:
Practice Address - Street 1:535 W. 4TH STREET APT. 201
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802
Practice Address - Country:US
Practice Address - Phone:805-905-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10099225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant