Healthcare Provider Details

I. General information

NPI: 1740367374
Provider Name (Legal Business Name): RODOLFO VALENZUELA IV NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RUDY VALENZUELA NP

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 E. JUAN SANCHEZ BLVD. 2
SAN LUIS AZ
85349-6805
US

IV. Provider business mailing address

PO BOX 7053 1914 E. JUAN SANCHEZ BLVD. STE. 2
SAN LUIS AZ
85349-6805
US

V. Phone/Fax

Practice location:
  • Phone: 928-627-2055
  • Fax: 928-627-2456
Mailing address:
  • Phone: 928-627-2055
  • Fax: 928-627-2456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15970
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP1549
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9209973
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: