Provider Demographics
NPI:1447606991
Name:ILLESCA, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:ILLESCA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22054 SHAW RD
Mailing Address - Street 2:STE H
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-9321
Mailing Address - Country:US
Mailing Address - Phone:571-268-9858
Mailing Address - Fax:571-313-1147
Practice Address - Street 1:22054 SHAW RD
Practice Address - Street 2:STE H
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-9321
Practice Address - Country:US
Practice Address - Phone:571-268-9858
Practice Address - Fax:571-313-1147
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA277343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)