=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407454838
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREDDY DE LAS CASAS NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2020
-----------------------------------------------------
Last Update Date | 10/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13940 SW 156TH TER
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33177-1081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-967-0128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13940 SW 156TH TER
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33177-1081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-967-0128
-----------------------------------------------------
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 | APRN11009504
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------