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General NPI Number Information
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NPI Number | 1063268209
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Entity Type | Individual
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Provider Name | WILSON OMAR RODRIGUEZ PA
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Gender | Male
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Dates
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Enumeration Date | 04/29/2024
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Last Update Date | 05/24/2024
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Provider Practice Location Address
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Address Line | 217 E CENTRAL AVE
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City | WINTER HAVEN
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State | FL
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Zip | 33880-6312
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Country | US
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Telephone | 407-315-3637
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 532
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City | LAKE ALFRED
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State | FL
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Zip | 33850-0532
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Country | US
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Telephone | 407-315-3637
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Fax | 407-358-3440
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2146-PA
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | TPPA690
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License Number State | FL
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