Provider Demographics
NPI:1477095164
Name:VALDES, LUIS G
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:G
Last Name:VALDES
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 1:367 S. GULPH RD
Mailing Address - Street 2:ATTN: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:803-648-1318
Mailing Address - Fax:
Practice Address - Street 1:410 UNIVERSITY PKWY STE 2310
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801
Practice Address - Country:US
Practice Address - Phone:803-648-1318
Practice Address - Fax:803-642-7803
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110014363A00000X
SC2719363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant