MEDICARE: JAIME EMMANUEL VALLES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN158684	AZ
2	363L00000X	Nurse Practitioner	219043	AZ

General Provider Information

NPI Number	:	1457826224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAIME EMMANUEL VALLES

Provider Business Mailing Address
First Line	:	PO BOX 617
Second Line	:
City	:	SOMERTON
State	:	AZ
Zip	:	85350-0617
Country	:	US
Telephone Number	:	928-315-7910
Fax Number	:

Provider Business Practice Location Address
First Line	:	1233 N MAIN ST STE 1A
Second Line	:
City	:	SAN LUIS
State	:	AZ
Zip	:	85336-0663
Country	:	US
Telephone Number	:	928-550-5514
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2018
Last Update Date	:	08/19/2024

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