Provider Demographics
NPI:1699189522
Name:MALDONADO, ANDRES
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:MALDONADO
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 1:2026 N IMPERIAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-1607
Mailing Address - Country:US
Mailing Address - Phone:760-592-4351
Mailing Address - Fax:
Practice Address - Street 1:2026 N IMPERIAL AVE STE C
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-1607
Practice Address - Country:US
Practice Address - Phone:760-592-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207502164X00000X
CA95021143363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No164X00000XNursing Service ProvidersLicensed Vocational Nurse