Provider Demographics
NPI:1124871801
Name:VANDENHENGELGOMEZ, VIRIDIANA SIMONA (PA65426)
Entity type:Individual
Prefix:
First Name:VIRIDIANA
Middle Name:SIMONA
Last Name:VANDENHENGELGOMEZ
Suffix:
Gender:F
Credentials:PA65426
Other - Prefix:
Other - First Name:VIRIDIANA
Other - Middle Name:SIMONA
Other - Last Name:VAN DEN HENGEL-GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA65426
Mailing Address - Street 1:224 RALEIGH DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-6636
Mailing Address - Country:US
Mailing Address - Phone:530-787-3454
Mailing Address - Fax:530-795-3054
Practice Address - Street 1:172 E GRANT AVE
Practice Address - Street 2:
Practice Address - City:WINTERS
Practice Address - State:CA
Practice Address - Zip Code:95694-1780
Practice Address - Country:US
Practice Address - Phone:916-734-2145
Practice Address - Fax:530-795-3054
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant