=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134333032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROQUE ENRIQUE VALLABRIGAS PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 04/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 258 NE 27TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33137-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-573-9898
-----------------------------------------------------
Fax | 305-573-3711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 924165
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33092-4165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-573-9898
-----------------------------------------------------
Fax | 305-573-3711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9100862
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------