Healthcare Provider Details

I. General information

NPI: 1861779951
Provider Name (Legal Business Name): JOSEPH SOLORIO DE LA CRUZ JR. PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

V. Phone/Fax

Practice location:
  • Phone: 901-450-4722
  • Fax:
Mailing address:
  • Phone: 901-450-4722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60413
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7231
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: