Healthcare Provider Details

I. General information

NPI: 1669043972
Provider Name (Legal Business Name): EDUARDO ARMANDO ROQUESO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 03/16/2024
Certification Date: 03/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17061 NW 82ND AVE
HIALEAH FL
33015-3701
US

IV. Provider business mailing address

17061 NW 82ND AVE
HIALEAH FL
33015-3701
US

V. Phone/Fax

Practice location:
  • Phone: 786-525-4933
  • Fax:
Mailing address:
  • Phone: 786-525-4933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11005275
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: