Provider Demographics
NPI:1629234893
Name:CHAVEZ, JOSE CARLOS (NP)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:CARLOS
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17299 CREMELLO WAY
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 W HIGHLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3855
Practice Address - Country:US
Practice Address - Phone:909-886-7576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14641364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629234893Medicaid