Healthcare Provider Details

I. General information

NPI: 1013115120
Provider Name (Legal Business Name): MARIO HEREDIA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARIO ALFREDO HEREDIA BLANCO PA-C

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E ALTAMONTE DR STE 210
ALTAMONTE SPRINGS FL
32701-4824
US

IV. Provider business mailing address

3127 W HALLANDALE BEACH BLVD #102
HALLANDALE FL
33009-5150
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-5452
  • Fax: 407-303-5448
Mailing address:
  • Phone: 866-816-7846
  • Fax: 954-458-2928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108764
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: