Provider Demographics
NPI:1609698711
Name:VENEGAS, LUIS ISAAC
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ISAAC
Last Name:VENEGAS
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 1:207 W LEGION RD
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-7780
Mailing Address - Country:US
Mailing Address - Phone:760-351-4400
Mailing Address - Fax:
Practice Address - Street 1:207 W LEGION RD
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7780
Practice Address - Country:US
Practice Address - Phone:760-351-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032172363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily