Provider Demographics
NPI:1952069270
Name:ARCHULETA, JOVAN PRUDENCIO
Entity Type:Individual
Prefix:
First Name:JOVAN
Middle Name:PRUDENCIO
Last Name:ARCHULETA
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 1:7335 E PALMER WASILLA HWY STE 2B
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-7710
Mailing Address - Country:US
Mailing Address - Phone:907-745-6200
Mailing Address - Fax:
Practice Address - Street 1:7335 E PALMER WASILLA HWY STE 2B
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7710
Practice Address - Country:US
Practice Address - Phone:907-745-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program