Healthcare Provider Details

I. General information

NPI: 1033534433
Provider Name (Legal Business Name): LUIS MARIANO ROQUETA SR. SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2014
Last Update Date: 02/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 NW 95TH ST STE # 306
MIAMI FL
33150-2063
US

IV. Provider business mailing address

1190 NW 95TH ST STE # 306
MIAMI FL
33150-2063
US

V. Phone/Fax

Practice location:
  • Phone: 305-693-0000
  • Fax:
Mailing address:
  • Phone: 305-693-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number13-486
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: