Healthcare Provider Details

I. General information

NPI: 1063656155
Provider Name (Legal Business Name): CONVENIENT PRACTITIONER SERVICES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10641 SW 37TH PL
DAVIE FL
33328-1310
US

IV. Provider business mailing address

10641 SW 37TH PL
DAVIE FL
33328-1310
US

V. Phone/Fax

Practice location:
  • Phone: 954-861-7522
  • Fax: 954-916-9436
Mailing address:
  • Phone: 954-861-7522
  • Fax: 954-916-9436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberARNP1737192
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP1737192
License Number StateFL

VIII. Authorized Official

Name: MS. IGDALIS ROLDAN CHRISTEN
Title or Position: PRESIDENT
Credential: ARNP
Phone: 954-861-7522