Provider Demographics
NPI:1992154645
Name:VALENCIA, EDWARD
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:VALENCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 SUNRISE RD
Mailing Address - Street 2:
Mailing Address - City:SAN FELIPE PB
Mailing Address - State:NM
Mailing Address - Zip Code:87001-8019
Mailing Address - Country:US
Mailing Address - Phone:505-771-9900
Mailing Address - Fax:
Practice Address - Street 1:176 SUNRISE RD
Practice Address - Street 2:
Practice Address - City:SAN FELIPE PB
Practice Address - State:NM
Practice Address - Zip Code:87001-8019
Practice Address - Country:US
Practice Address - Phone:505-771-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM436175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist