Provider Demographics
NPI:1295124485
Name:VELAZQUEZ, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:VELAZQUEZ
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 1:17212 N ROSA DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-1835
Mailing Address - Country:US
Mailing Address - Phone:309-299-0118
Mailing Address - Fax:
Practice Address - Street 1:17212 N ROSA DR
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-1835
Practice Address - Country:US
Practice Address - Phone:309-299-0118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041368600367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered