Provider Demographics
NPI:1538907845
Name:VEGA, KEVIN A (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:VEGA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1573 W FAIRBANKS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4679
Mailing Address - Country:US
Mailing Address - Phone:407-896-8097
Mailing Address - Fax:407-898-8328
Practice Address - Street 1:1573 W FAIRBANKS AVE STE 100
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4679
Practice Address - Country:US
Practice Address - Phone:407-896-8097
Practice Address - Fax:407-898-8328
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9119217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program