Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 234060 | AZ |
N | 363LA2100X | Nurse Practitioner - Acute Care | 234060 | AZ |
N | 363LG0600X | Nurse Practitioner - Gerontology | 234060 | AZ |
NPI | 1023667862 |
---|---|
Provider Name | Mario Vazquez |
First Address | Yuma, AZ 85364 |
Second Address | Yuma, AZ 85364-7189 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/09/2019 |
Last Update Date | 11/05/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
600512 | (05) | AZ |