Healthcare Provider Details

I. General information

NPI: 1801623251
Provider Name (Legal Business Name): ALEXIS PEDRO FERNANDEZ DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 NW 110TH AVE STE 218
MIAMI FL
33172-1929
US

IV. Provider business mailing address

12901 SW 148TH TERRACE RD
MIAMI FL
33186-6311
US

V. Phone/Fax

Practice location:
  • Phone: 305-456-7580
  • Fax:
Mailing address:
  • Phone: 786-603-5358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11035389
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: