Provider Demographics
NPI:1982211785
Name:VELASCO VARGAS, WILFREDO ANTONIO (RN)
Entity type:Individual
Prefix:
First Name:WILFREDO
Middle Name:ANTONIO
Last Name:VELASCO VARGAS
Suffix:
Gender:M
Credentials:RN
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Other - Middle Name:
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Mailing Address - Street 1:74 CALLE SANTA CRUZ APT PHG
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-7083
Mailing Address - Country:US
Mailing Address - Phone:310-906-7434
Mailing Address - Fax:
Practice Address - Street 1:6041 CADILLAC AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-1702
Practice Address - Country:US
Practice Address - Phone:562-373-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN246957163W00000X
PR099694163W00000X
CA95042984163W00000X
CANA95002659367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse