Healthcare Provider Details

I. General information

NPI: 1861560427
Provider Name (Legal Business Name): IVAN PATINO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 N KENDALL DR
MIAMI FL
33176-2118
US

IV. Provider business mailing address

PO BOX 198054
ATLANTA GA
30384-1980
US

V. Phone/Fax

Practice location:
  • Phone: 786-596-6743
  • Fax:
Mailing address:
  • Phone: 786-594-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9102100
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102100
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: