Healthcare Provider Details

I. General information

NPI: 1134720972
Provider Name (Legal Business Name): ALESSANDRA MARIE VALENZUELA PORFIDO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALESSANDRA MARIE PORFIDO PA-C

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 FLORIDA AVE
MODESTO CA
95350-4437
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 866-682-4842
  • Fax:
Mailing address:
  • Phone: 866-682-4842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58758
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: