Healthcare Provider Details

I. General information

NPI: 1679767941
Provider Name (Legal Business Name): JUAN MANUEL DE OLEO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NW 35TH AVE
MIAMI FL
33125-4000
US

IV. Provider business mailing address

600 NW 35TH AVE
MIAMI FL
33125-4000
US

V. Phone/Fax

Practice location:
  • Phone: 305-642-3724
  • Fax: 305-643-2228
Mailing address:
  • Phone: 305-642-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101496
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: