=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881726032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESUS MANUEL PEREIRA PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12423 SW 104TH LN
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-3610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-301-4046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12423 SW 104TH LN
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-3610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-301-4046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | PA 9101868
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------