Provider Demographics
NPI:1467854208
Name:VALLADARES, SIMON E (PA-C)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:E
Last Name:VALLADARES
Suffix:
Gender:M
Credentials:PA-C
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 198175
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8175
Mailing Address - Country:US
Mailing Address - Phone:305-595-1317
Mailing Address - Fax:305-279-6813
Practice Address - Street 1:11801 SW 90TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-2182
Practice Address - Country:US
Practice Address - Phone:305-595-1317
Practice Address - Fax:305-279-6813
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650667458OtherTAXPAYER IDENTIFICATION