Healthcare Provider Details

I. General information

NPI: 1982182184
Provider Name (Legal Business Name): RUBENS DE LA PENA MIR APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 BROWN CHAPEL RD
SAINT CLOUD FL
34769-2043
US

IV. Provider business mailing address

4212 FLORA VISTA DR
ORLANDO FL
32837-4794
US

V. Phone/Fax

Practice location:
  • Phone: 786-970-2112
  • Fax:
Mailing address:
  • Phone: 786-970-2112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9401713
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN9401713
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: