MEDICARE: MR. JOSE SAMUEL FUENTES ROMAN PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	021-P.A.	PR
2	390200000X	Student in an Organized Health Care Education/Training Program	17746-I	PR

General Provider Information

NPI Number	:	1376129809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSE SAMUEL FUENTES ROMAN PA

Provider Business Mailing Address
First Line	:	PO BOX 3102
Second Line	:
City	:	ARECIBO
State	:	PR
Zip	:	00613-3102
Country	:	US
Telephone Number	:	787-363-0228
Fax Number	:

Provider Business Practice Location Address
First Line	:	531 AVE MIRAMAR
Second Line	:
City	:	ARECIBO
State	:	PR
Zip	:	00612-4360
Country	:	US
Telephone Number	:	787-817-1383
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2021
Last Update Date	:	06/07/2026

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