Provider Demographics
NPI:1710431614
Name:VELASCO, ROQUE ANTHONY FULGENCIO (NP)
Entity Type:Individual
Prefix:
First Name:ROQUE ANTHONY
Middle Name:FULGENCIO
Last Name:VELASCO
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 1:1695 N SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-3701
Mailing Address - Country:US
Mailing Address - Phone:760-323-2118
Mailing Address - Fax:
Practice Address - Street 1:1695 N SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-3701
Practice Address - Country:US
Practice Address - Phone:760-323-3118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004619363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care