Provider Demographics
NPI:1184102758
Name:VELASCO, MARIA COREENA VENGCO (MS, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:MARIA COREENA
Middle Name:VENGCO
Last Name:VELASCO
Suffix:
Gender:F
Credentials:MS, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 POTRERO AVE
Mailing Address - Street 2:BLDG 1, RM 101
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110
Mailing Address - Country:US
Mailing Address - Phone:415-206-8000
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:BLDG 1, RM 101
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110
Practice Address - Country:US
Practice Address - Phone:415-206-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-05
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009736363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care