Healthcare Provider Details

I. General information

NPI: 1013432798
Provider Name (Legal Business Name): MITDAEL MORENO APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12320 QUAIL ROOST DR
MIAMI FL
33177-4930
US

IV. Provider business mailing address

6100 BLUE LAGOON DR STE 365
MIAMI FL
33126-7010
US

V. Phone/Fax

Practice location:
  • Phone: 786-237-3070
  • Fax: 786-430-8198
Mailing address:
  • Phone: 786-322-7333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9292469
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: