Basic Information
Provider Information | |||||||||
NPI: | 1114389665 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VEGA | ||||||||
FirstName: | FARAH | ||||||||
MiddleName: | ESTHER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3299 | ||||||||
Address2: |   | ||||||||
City: | CARSON CITY | ||||||||
State: | NV | ||||||||
PostalCode: | 897023299 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7752220042 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3100 CHANNING WAY | ||||||||
Address2: |   | ||||||||
City: | IDAHO FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 834047533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2085296111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2016 | ||||||||
LastUpdateDate: | 10/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | M-14866 | ID | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | MRM-1559 | 01 | ID | STATE OF IDAHO BOARD OF MEDICINE | OTHER |