Healthcare Provider Details

I. General information

NPI: 1700090099
Provider Name (Legal Business Name): WELLINGTON A ESQUEA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 BOREN DR SUITE A
OCOEE FL
34761-2966
US

IV. Provider business mailing address

1551 BOREN DR STE A
OCOEE FL
34761-2966
US

V. Phone/Fax

Practice location:
  • Phone: 407-877-8300
  • Fax: 407-877-8841
Mailing address:
  • Phone: 407-395-2037
  • Fax: 407-395-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9100791
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: