Healthcare Provider Details

I. General information

NPI: 1497881692
Provider Name (Legal Business Name): ENRIQUE RUIZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2007
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 DEL PRADO BLVD N STE 201
CAPE CORAL FL
33909-2278
US

IV. Provider business mailing address

632 DEL PRADO BLVD N STE 201
CAPE CORAL FL
33909-2278
US

V. Phone/Fax

Practice location:
  • Phone: 239-829-7102
  • Fax:
Mailing address:
  • Phone: 239-829-7102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9104245
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-00772
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA91042445
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: