1063078897 NPI number — LAURA MONICA MANOSALVA VARGAS PA-C

Table of content: LAURA MONICA MANOSALVA VARGAS PA-C (NPI 1063078897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063078897 NPI number — LAURA MONICA MANOSALVA VARGAS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANOSALVA VARGAS
Provider First Name:
LAURA
Provider Middle Name:
MONICA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VARGAS
Provider Other First Name:
LAURA
Provider Other Middle Name:
MONICA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063078897
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4175 W BROADWAY APT C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAWTHORNE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90250-4097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-213-2902
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11301 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
BLDG.500, NSGY SUITE 6664
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-478-3711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  56793 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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