Provider Demographics
NPI:1255166153
Name:CARONAN, JOSE MARI C II
Entity type:Individual
Prefix:MR
First Name:JOSE MARI
Middle Name:C
Last Name:CARONAN
Suffix:II
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 1:4509 QUEENS HILL ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-2282
Mailing Address - Country:US
Mailing Address - Phone:310-818-1772
Mailing Address - Fax:
Practice Address - Street 1:4509 QUEENS HILL ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2282
Practice Address - Country:US
Practice Address - Phone:310-818-1772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-1476225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant