Provider Demographics
NPI:1568092872
Name:ZULUAGA BEDOYA, JUAN CARLOS (SA-C)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:ZULUAGA BEDOYA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5836 STONECREST DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-0226
Mailing Address - Country:US
Mailing Address - Phone:901-626-4635
Mailing Address - Fax:
Practice Address - Street 1:6885 CLUB RIDGE CIR APT 87
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-7327
Practice Address - Country:US
Practice Address - Phone:901-626-4635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-26
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20-104246ZC0007X
TN272280163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant