Provider Demographics
NPI:1790370823
Name:FLORES VILLANUEVA, JESUS VALENTIN (SA-C)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:VALENTIN
Last Name:FLORES VILLANUEVA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 FOOTHILLS RD APT H1
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-3618
Mailing Address - Country:US
Mailing Address - Phone:915-207-4570
Mailing Address - Fax:
Practice Address - Street 1:3500 FOOTHILLS RD APT H1
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-3618
Practice Address - Country:US
Practice Address - Phone:915-207-4570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21-154246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant