Provider Demographics
NPI:1679046601
Name:PENALOSA, RICHARD VALDERAS JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:VALDERAS
Last Name:PENALOSA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:VALDERAS
Other - Last Name:PENALOSA
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:APN
Mailing Address - Street 1:409 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753
Mailing Address - Country:US
Mailing Address - Phone:732-447-6937
Mailing Address - Fax:
Practice Address - Street 1:409 LOCUST ST
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753
Practice Address - Country:US
Practice Address - Phone:732-447-6937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00853100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner