Healthcare Provider Details

I. General information

NPI: 1225893589
Provider Name (Legal Business Name): MARCELO JAVIER MOYANO APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 NW 12TH AVE FL 3
MIAMI FL
33136-1002
US

IV. Provider business mailing address

1475 NW 12TH AVE FL 3
MIAMI FL
33136-1002
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-7569
  • Fax: 305-243-7569
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11030502
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: