Healthcare Provider Details

I. General information

NPI: 1417819855
Provider Name (Legal Business Name): JOSE RUIZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15420 LIVINGSTON AVE APT 2412
LUTZ FL
33559-3410
US

IV. Provider business mailing address

15420 LIVINGSTON AVE APT 2412
LUTZ FL
33559-3410
US

V. Phone/Fax

Practice location:
  • Phone: 561-932-4483
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: