Provider Demographics
NPI:1366993362
Name:MEHTA, VANESSA JULIE IGLESIAS (PA-C)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:JULIE IGLESIAS
Last Name:MEHTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:JULIE
Other - Last Name:IGLESIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5128 YELM HWY SE
Mailing Address - Street 2:SUITE E
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503
Mailing Address - Country:US
Mailing Address - Phone:708-652-2040
Mailing Address - Fax:
Practice Address - Street 1:5128 YELM HWY SE
Practice Address - Street 2:SUITE E
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503
Practice Address - Country:US
Practice Address - Phone:708-652-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005976363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical