Basic Information
| Provider Information | |||||||||
| NPI: | 1225197668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASQUEZ-BYNUM | ||||||||
| FirstName: | VERONICA | ||||||||
| MiddleName: | TERESA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241449 | ||||||||
| FaxNumber: | 2394241421 | ||||||||
| Practice Location | |||||||||
| Address1: | 8960 COLONIAL CENTER DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339057810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439633 | ||||||||
| FaxNumber: | 2393439635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 05/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9105013 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA03122 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 001540600 | 05 | FL | MEDICAID |