Provider Demographics
NPI:1578787917
Name:VELASQUEZ, KENNETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:VELASQUEZ
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 1:400 N PEPPER AVE
Mailing Address - Street 2:ORTHOPAEDIC ADMINISTRATION
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1801
Mailing Address - Country:US
Mailing Address - Phone:909-580-6330
Mailing Address - Fax:909-580-6369
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:ORTHOPAEDIC ADMINISTRATION
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-6330
Practice Address - Fax:909-580-6369
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA12714Medicare UPIN