Basic Information
| Provider Information | |||||||||
| NPI: | 1487853354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VARELA | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | JOAQUIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT MHSC MTC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 181 MOSES CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | ST. AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046161282 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5210 CORPORATE CENTER CT SE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985035952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604558155 | ||||||||
| FaxNumber: | 3604551655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 07/29/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60017380 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | 18058 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 236094 | 01 | WA | L&I | OTHER | 2767VA | 01 | WA | REGENCE | OTHER | 8525339 | 01 | WA | DSHS | OTHER | 3456VA | 01 | WA | REGENCE | OTHER | G8873416 | 01 | WA | MEDICARE | OTHER | 8947463 | 01 | WA | L&I CRIME | OTHER | 2769VA | 01 | WA | REGENCE | OTHER | 2766VA | 01 | WA | REGENCE | OTHER | 6788VA | 01 | WA | REGENCE | OTHER |