Provider Demographics
NPI:1164803078
Name:VALLADARES GONZALEZ, MANUEL (APRN)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:VALLADARES GONZALEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4189
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-4189
Mailing Address - Country:US
Mailing Address - Phone:954-363-9582
Mailing Address - Fax:
Practice Address - Street 1:15700 NW 67TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2112
Practice Address - Country:US
Practice Address - Phone:786-434-5987
Practice Address - Fax:786-434-5988
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11039712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL127290200Medicaid