Healthcare Provider Details

I. General information

NPI: 1144787458
Provider Name (Legal Business Name): IVAN LORENZO VIERA- SAN MARTIN MSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 PLAZA FABIOLA ESTANCIAS DE CERRO GORDO
VEGA ALTA PR
00692-9125
US

IV. Provider business mailing address

78 PLAZA FABIOLA ESTANCIAS DE CERRO GORDO
VEGA ALTA PR
00692-9125
US

V. Phone/Fax

Practice location:
  • Phone: 787-717-2568
  • Fax:
Mailing address:
  • Phone: 787-717-2568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberE1779
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: