Healthcare Provider Details

I. General information

NPI: 1124634464
Provider Name (Legal Business Name): MARCELINO AMEZQUITA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARCELINO AMEZQUITA ARNP

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10250 SW 56TH ST STE C101
MIAMI FL
33165-7065
US

IV. Provider business mailing address

10250 SW 56TH ST STE C101
MIAMI FL
33165-7065
US

V. Phone/Fax

Practice location:
  • Phone: 135-257-5570
  • Fax:
Mailing address:
  • Phone: 786-558-8901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11009130
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: