Provider Demographics
NPI:1740367374
Name:VALENZUELA, RODOLFO IV (NP)
Entity type:Individual
Prefix:MR
First Name:RODOLFO
Middle Name:
Last Name:VALENZUELA
Suffix:IV
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:RUDY
Other - Middle Name:
Other - Last Name:VALENZUELA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 7053
Mailing Address - Street 2:1914 E. JUAN SANCHEZ BLVD. STE. 2
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349-6805
Mailing Address - Country:US
Mailing Address - Phone:928-627-2055
Mailing Address - Fax:928-627-2456
Practice Address - Street 1:1914 E. JUAN SANCHEZ BLVD.
Practice Address - Street 2:2
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349-6805
Practice Address - Country:US
Practice Address - Phone:928-627-2055
Practice Address - Fax:928-627-2456
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15970363LF0000X
AZAP1549363LF0000X
FL9209973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ717267Medicaid
Q19863Medicare UPIN
AZ717267Medicaid