Healthcare Provider Details

I. General information

NPI: 1316811151
Provider Name (Legal Business Name): PABLO ROMAN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: PABLO AYALA

II. Dates (important events)

Enumeration Date: 10/03/2025
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14844 SUMMER BRANCH DR
LITHIA FL
33547-5130
US

IV. Provider business mailing address

14844 SUMMER BRANCH DR
LITHIA FL
33547-5130
US

V. Phone/Fax

Practice location:
  • Phone: 786-314-6348
  • Fax:
Mailing address:
  • Phone: 786-314-6348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11049289
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9637403
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: