Healthcare Provider Details

I. General information

NPI: 1114106051
Provider Name (Legal Business Name): GUILLERMO LORENZO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2007
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 E MICHIGAN ST STE 103
ORLANDO FL
32822-2700
US

IV. Provider business mailing address

5555 E MICHIGAN ST STE 103
ORLANDO FL
32822-2700
US

V. Phone/Fax

Practice location:
  • Phone: 407-456-2977
  • Fax: 407-745-4688
Mailing address:
  • Phone: 407-456-2977
  • Fax: 407-745-4688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number9100415
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9100415
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: