Provider Demographics
NPI:1740492289
Name:VELASCO, RAY (ACNP)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:VELASCO
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 E HIGHLAND AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3808
Mailing Address - Country:US
Mailing Address - Phone:909-881-7400
Mailing Address - Fax:909-881-7404
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3808
Practice Address - Country:US
Practice Address - Phone:909-881-7400
Practice Address - Fax:909-881-7404
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care