Provider Demographics
NPI:1689225617
Name:ZAVALA, JUAN JOSE
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:ZAVALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6534 MACARENA DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-6447
Mailing Address - Country:US
Mailing Address - Phone:210-429-2555
Mailing Address - Fax:
Practice Address - Street 1:3765 S ALAMEDA ST STE 251
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1655
Practice Address - Country:US
Practice Address - Phone:361-937-7887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX929097163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX929097OtherRN