Provider Demographics
NPI:1053461285
Name:VALDIVIA, JOSE ANGEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANGEL
Last Name:VALDIVIA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10401 W THUNDERBIRD BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3004
Mailing Address - Country:US
Mailing Address - Phone:623-876-5366
Mailing Address - Fax:866-552-8029
Practice Address - Street 1:10401 W THUNDERBIRD BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3004
Practice Address - Country:US
Practice Address - Phone:623-876-5366
Practice Address - Fax:866-552-8029
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2145363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ455809Medicaid
AZ579522Medicare UPIN