Healthcare Provider Details

I. General information

NPI: 1134520380
Provider Name (Legal Business Name): WILFREDO NOEL TIJERINO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6141 SUNSET DR STE 403
SOUTH MIAMI FL
33143-5026
US

IV. Provider business mailing address

5312 SW 152ND CT
MIAMI FL
33185-4129
US

V. Phone/Fax

Practice location:
  • Phone: 305-663-8877
  • Fax:
Mailing address:
  • Phone: 305-803-5916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108185
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9108185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: