Basic Information
| Provider Information | |||||||||
| NPI: | 1255823787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALDES | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 S TAMPANIA AVE UNIT 4 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336093631 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 W DR MARTIN LUTHER KING JR BLVD | ||||||||
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| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138704000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2018 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | AA579 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | AA579 | 01 | FL | STATE LICENSE | OTHER |