Healthcare Provider Details

I. General information

NPI: 1124953112
Provider Name (Legal Business Name): EMILIO ANDRES MALAVE-LAZARO AT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 59
GUAYNABO PR
00970-0059
US

IV. Provider business mailing address

PO BOX 59
GUAYNABO PR
00970-0059
US

V. Phone/Fax

Practice location:
  • Phone: 787-689-0504
  • Fax:
Mailing address:
  • Phone: 787-689-0504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: