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General NPI Number Information
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NPI Number | 1114669140
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Entity Type | Individual
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Provider Name | RAQUEL ITA BEREZDIVIN PA-C
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Gender | Female
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Dates
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Enumeration Date | 04/11/2022
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Last Update Date | 10/28/2022
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Provider Practice Location Address
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Address Line | 1511 AVENIDA DE LA CONSTITUCION SUITE 3
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City | SAN JUAN
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State | PR
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Zip | 00909
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Country | US
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Telephone | 787-339-2639
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Fax |
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Provider Business Mailing Address
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Address Line | 54 CALLE CALISTEMON
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City | GUAYNABO
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State | PR
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Zip | 00966-3166
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Country | US
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Telephone | 786-223-7624
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Fax |
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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 | PA9113995
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 845PA
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License Number State | PR
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