Healthcare Provider Details

I. General information

NPI: 1073546933
Provider Name (Legal Business Name): JOSE ANTONIO PUERTO PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18610 NW 87TH AVE SUITE 101 AND 201
HIALEAH FL
33015-3518
US

IV. Provider business mailing address

8400 NW 33RD ST SUITE 201
DORAL FL
33122-1937
US

V. Phone/Fax

Practice location:
  • Phone: 305-829-5000
  • Fax: 305-829-5033
Mailing address:
  • Phone: 786-408-8502
  • Fax: 305-402-0855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9100243
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: