Healthcare Provider Details

I. General information

NPI: 1972009066
Provider Name (Legal Business Name): WICKANDER FERREIRA MLT (ASCP)CM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18100 W DIXIE HWY STE 205
NORTH MIAMI BEACH FL
33160-2059
US

IV. Provider business mailing address

18100 W DIXIE HWY STE 205
NORTH MIAMI BEACH FL
33160-2059
US

V. Phone/Fax

Practice location:
  • Phone: 305-704-8503
  • Fax:
Mailing address:
  • Phone: 305-704-8503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code246Q00000X
TaxonomyPathology Specialist/Technologist
License NumberTC52623
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: