Basic Information
| Provider Information | |||||||||
| NPI: | 1962625699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALENZUELA | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | EMILIO | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 RAYNOLDS ST # 51015 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799051613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152154480 | ||||||||
| FaxNumber: | 9152155386 | ||||||||
| Practice Location | |||||||||
| Address1: | 4801 ALBERTA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152155000 | ||||||||
| FaxNumber: | 9152158632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | AP126993 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 36046900 | 05 | WI | MEDICAID |