Healthcare Provider Details

I. General information

NPI: 1053011882
Provider Name (Legal Business Name): ROY RODRIGUEZ PANESSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COUNTRY CLUB 215 HB1
CAROLINA PUERTO RICO
00982
UM

IV. Provider business mailing address

COUNTRY CLUB 215 HB1
CAROLINA PUERTO RICO
00982
UM

V. Phone/Fax

Practice location:
  • Phone: 787-399-0434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1591
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: