Healthcare Provider Details

I. General information

NPI: 1699704239
Provider Name (Legal Business Name): OMAR FUNDORA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W 68TH ST
HIALEAH FL
33016-1801
US

IV. Provider business mailing address

4744 SW 195TH WAY
MIRAMAR FL
33029-6203
US

V. Phone/Fax

Practice location:
  • Phone: 786-478-9397
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP 9170887
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: