Basic Information
| Provider Information | |||||||||
| NPI: | 1669407243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DORSEY | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2200 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923730722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097933311 | ||||||||
| FaxNumber: | 9097964158 | ||||||||
| Practice Location | |||||||||
| Address1: | 7000 BOULDER AVE | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923463348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098621191 | ||||||||
| FaxNumber: | 9097964158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA13832 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA13832 | 05 | CA | MEDICAID |