Provider Demographics
NPI:1447938337
Name:VALENZUELA, RANDOLPH
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:VALENZUELA
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 1:3401 SOUTHERN BREEZE AVE
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78541-4456
Mailing Address - Country:US
Mailing Address - Phone:956-897-3934
Mailing Address - Fax:
Practice Address - Street 1:5505 S EXPRESSWAY 77 STE 203
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-3222
Practice Address - Country:US
Practice Address - Phone:956-444-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1128035363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner