Provider Demographics
NPI:1366584633
Name:VALLADARES, JENNIFER (RPA-C)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:VALLADARES
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 PROSPECT PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4074
Mailing Address - Country:US
Mailing Address - Phone:917-716-3810
Mailing Address - Fax:
Practice Address - Street 1:827 PROSPECT PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4074
Practice Address - Country:US
Practice Address - Phone:917-716-3810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0060129-1363AS0400X
CA54334363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA54334OtherCA STATE LICENSE NUMBER
NY006129-1OtherNY STATE LICENSE NUMBER