Provider Demographics
NPI:1265085344
Name:ANDAVERDE, JUAN M
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:M
Last Name:ANDAVERDE
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 1:4468 E KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-3605
Mailing Address - Country:US
Mailing Address - Phone:559-600-9500
Mailing Address - Fax:
Practice Address - Street 1:4468 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3605
Practice Address - Country:US
Practice Address - Phone:559-203-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker