Basic Information
| Provider Information | |||||||||
| NPI: | 1386124485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VEGA MALDONADO | ||||||||
| FirstName: | JESUS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | PROF. | ||||||||
| NameSuffix: | |||||||||
| Credential: | 02549 MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | BO BELGICA CALLE CAMPOS #2210 | ||||||||
| Address2: | |||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876276297 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | CONSOLIDATED MALL B5 | ||||||||
| Address2: | AVE. GAUTIER BENITEZ 202 | ||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877040705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2018 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 2549 | PR | Y | Nursing Service Providers | Registered Nurse | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 2549 | 01 | PR | NURSE | OTHER |