Basic Information
| Provider Information | |||||||||
| NPI: | 1922327568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | IRBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634074 | ||||||||
| FaxNumber: | 9074631510 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 TONGASS DR | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998359416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079668318 | ||||||||
| FaxNumber: | 9079668606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2010 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT196939 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MEDS7915 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MEDS7915 | 01 | AK | STATE OF ALASKA | OTHER | 1599661 | 05 | AK | MEDICAID |