Provider Demographics
NPI:1457826224
Name:VALLES, JAIME EMMANUEL
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:EMMANUEL
Last Name:VALLES
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:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-236-8001
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:1233 N MAIN ST STE 1A
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85336-0663
Practice Address - Country:US
Practice Address - Phone:928-550-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN158684163W00000X
AZ219043363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse