Healthcare Provider Details

I. General information

NPI: 1679236798
Provider Name (Legal Business Name): MARIO LUIS MORERA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 SW 75TH AVE
MIAMI FL
33155-2805
US

IV. Provider business mailing address

8340 NW 10TH ST APT 6G
MIAMI FL
33126-2719
US

V. Phone/Fax

Practice location:
  • Phone: 305-264-5252
  • Fax:
Mailing address:
  • Phone: 786-728-2703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11030296
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: