Healthcare Provider Details

I. General information

NPI: 1720552789
Provider Name (Legal Business Name): WILFREDO PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

512 ROY BLVD
ALTAMONTE SPRINGS FL
32701-6850
US

V. Phone/Fax

Practice location:
  • Phone: 863-873-0442
  • Fax:
Mailing address:
  • Phone: 863-873-0442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9327965
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11002413
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: