Healthcare Provider Details

I. General information

NPI: 1477700722
Provider Name (Legal Business Name): MARIO ADRIAN REYES AGPCNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 NW 27TH AVE 130
MIAMI FL
33125-2157
US

IV. Provider business mailing address

1490 NW 27TH AVE 130
MIAMI FL
33125-2157
US

V. Phone/Fax

Practice location:
  • Phone: 305-635-7710
  • Fax: 305-637-8122
Mailing address:
  • Phone: 305-635-7710
  • Fax: 305-637-8122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP9316143
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9316143
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number02-128
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: