Provider Demographics
NPI:1902339823
Name:VEGSO, AMANDA NICOLE (PA, ATC)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:NICOLE
Last Name:VEGSO
Suffix:
Gender:F
Credentials:PA, ATC
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Mailing Address - Street 1:198 HILLSIDE ST APT 7
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3270
Mailing Address - Country:US
Mailing Address - Phone:920-213-4374
Mailing Address - Fax:
Practice Address - Street 1:500 W UNIVERSITY
Practice Address - Street 2:LKD
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79968
Practice Address - Country:US
Practice Address - Phone:915-747-6801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer