Healthcare Provider Details

I. General information

NPI: 1104488113
Provider Name (Legal Business Name): ANDRES RENE VELAZQUEZ P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 SW 27TH AVE STE 404
MIAMI FL
33135-2967
US

IV. Provider business mailing address

11230 SW 40TH TER
MIAMI FL
33165-4602
US

V. Phone/Fax

Practice location:
  • Phone: 305-926-9642
  • Fax:
Mailing address:
  • Phone: 305-926-9642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPACN110
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTPPA966
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000260-P.A.
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: