Healthcare Provider Details

I. General information

NPI: 1023222932
Provider Name (Legal Business Name): MYRNA MALDONADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO PASTO CARR #717 KM 9.8 INT
AIBONITO PR
00705-2021
US

IV. Provider business mailing address

PO BOX 927
BARRANQUITAS PR
00794-0927
US

V. Phone/Fax

Practice location:
  • Phone: 787-735-2401
  • Fax: 787-735-2500
Mailing address:
  • Phone: 787-735-2401
  • Fax: 787-735-2500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberAF5170
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: