=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104441161
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO IGNACIO QUINTANA MARTINEZ APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2020
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 W 9TH ST
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33010-3853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-360-4528
-----------------------------------------------------
Fax | 786-360-4529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2510 W 56TH ST APT 2320
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-4765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-210-3860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11006342
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------