Provider Demographics
NPI:1619525714
Name:VALLENILLA TOLOSA, JOEL JOSUE (SA-C)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:JOSUE
Last Name:VALLENILLA TOLOSA
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 1:14047 WALCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7471
Mailing Address - Country:US
Mailing Address - Phone:407-272-8505
Mailing Address - Fax:
Practice Address - Street 1:14047 WALCOTT AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7471
Practice Address - Country:US
Practice Address - Phone:407-272-8505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-01
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
FL17-398246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant