Healthcare Provider Details

I. General information

NPI: 1194446104
Provider Name (Legal Business Name): VRENA PUENTES CORCHERO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5860 RANCH LAKE BLVD
LAKEWOOD RANCH FL
34202-3718
US

IV. Provider business mailing address

3006 W RIO VISTA AVE
TAMPA FL
33614-5959
US

V. Phone/Fax

Practice location:
  • Phone: 941-388-8997
  • Fax:
Mailing address:
  • Phone: 813-482-5108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116505
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: