Healthcare Provider Details

I. General information

NPI: 1043975105
Provider Name (Legal Business Name): JORGE TASE APRN, FNP, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 04/05/2026
Certification Date: 04/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 NW 82ND AVE STE 408
DORAL FL
33166-7602
US

IV. Provider business mailing address

9501 FONTAINEBLEAU BLVD APT 401
MIAMI FL
33172-6820
US

V. Phone/Fax

Practice location:
  • Phone: 305-939-6877
  • Fax:
Mailing address:
  • Phone: 786-738-3682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023208786
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number2340260062
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF03230441
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9544203
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11025309
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11025309
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: