Provider Demographics
NPI:1982211785
Name:VELASCO VARGAS, WILFREDO ANTONIO (RN)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:ANTONIO
Last Name:VELASCO VARGAS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 CALLE SANTA CRUZ APT PHG
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-7083
Mailing Address - Country:US
Mailing Address - Phone:310-906-7434
Mailing Address - Fax:
Practice Address - Street 1:10 CALLE CASIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3200
Practice Address - Country:US
Practice Address - Phone:310-906-7434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN246957163W00000X
PR099694163W00000X
CA95042984163W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse