MEDICARE: MR. RAFAEL CARBALLO FNP-BC

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	163W00000X	Registered Nurse	9199568	FL
2	363LF0000X	Family Nurse Practitioner	11001321	FL

General Provider Information

NPI Number	:	1720269228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RAFAEL CARBALLO FNP-BC

Provider Business Mailing Address
First Line	:	2415 NW 16TH STREET RD APT 208
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33125-1292
Country	:	US
Telephone Number	:	786-301-9084
Fax Number	:

Provider Business Practice Location Address
First Line	:	2415 NW 16TH STREET RD APT 208
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33125-1292
Country	:	US
Telephone Number	:	786-301-9084
Fax Number	:

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

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	03/10/2020

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