Healthcare Provider Details

I. General information

NPI: 1235742776
Provider Name (Legal Business Name): JOSE LUIS VICTORERO SR. APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOSE LUIS VICTORERO I APRN

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 SW 57TH AVE
MIAMI FL
33144-3922
US

IV. Provider business mailing address

602 W 65TH DR
HIALEAH FL
33012-6559
US

V. Phone/Fax

Practice location:
  • Phone: 305-265-3239
  • Fax:
Mailing address:
  • Phone: 786-314-1361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11008713
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: