Provider Demographics
NPI:1487453817
Name:BALTAZAR, JUAN PABLO (MEDICAL STUDENT)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:PABLO
Last Name:BALTAZAR
Suffix:
Gender:M
Credentials:MEDICAL STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 HAVEN AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2654
Mailing Address - Country:US
Mailing Address - Phone:212-305-3595
Mailing Address - Fax:
Practice Address - Street 1:104 HAVEN AVE STE 105
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-2654
Practice Address - Country:US
Practice Address - Phone:212-305-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program