Provider Demographics
NPI:1972165660
Name:BANUELOS, JOSE (FNP)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 N SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-5201
Mailing Address - Country:US
Mailing Address - Phone:760-788-2210
Mailing Address - Fax:760-778-2214
Practice Address - Street 1:1490 6TH ST
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1712
Practice Address - Country:US
Practice Address - Phone:760-314-3714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013880363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily