Healthcare Provider Details

I. General information

NPI: 1073895017
Provider Name (Legal Business Name): EDWARD DE JESUS BOLANOS CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 SW 172ND AVE
MIRAMAR FL
33029-5592
US

IV. Provider business mailing address

7700 W SUNRISE BLVD
PLANTATION FL
33322-4113
US

V. Phone/Fax

Practice location:
  • Phone: 954-838-2371
  • Fax: 954-851-1746
Mailing address:
  • Phone: 954-838-2371
  • Fax: 954-851-1746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA97
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: