Provider Demographics
NPI:1497493589
Name:VALDEZ, GASPAR RICO IV
Entity Type:Individual
Prefix:
First Name:GASPAR
Middle Name:RICO
Last Name:VALDEZ
Suffix:IV
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 1:804 E GENTILE ST
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4330
Mailing Address - Country:US
Mailing Address - Phone:385-439-8137
Mailing Address - Fax:
Practice Address - Street 1:804 E GENTILE ST
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4330
Practice Address - Country:US
Practice Address - Phone:385-439-8137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT179013623Medicaid