Healthcare Provider Details

I. General information

NPI: 1194936112
Provider Name (Legal Business Name): NESJUAN FAELIO CARDONA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL BUEN SAMARITANO CARR #2 KM 141.1 AVE. KENNEDY
AGUADILLA PR
00603
US

IV. Provider business mailing address

PO BOX 1622
SAN SEBASTIAN PR
00685-1622
US

V. Phone/Fax

Practice location:
  • Phone: 787-819-0800
  • Fax:
Mailing address:
  • Phone: 787-896-6586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15155
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: