Healthcare Provider Details

I. General information

NPI: 1053614610
Provider Name (Legal Business Name): MARTIN DEL VALLE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2010
Last Update Date: 12/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9167 FONTAINEBLEAU BLVD APT 15
MIAMI FL
33172-6317
US

IV. Provider business mailing address

9167 FONTAINEBLEAU BLVD APT 15
MIAMI FL
33172-6317
US

V. Phone/Fax

Practice location:
  • Phone: 787-568-2868
  • Fax:
Mailing address:
  • Phone: 787-568-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9316981
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: