=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891438149
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYNNET EVE CORDERO PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2022
-----------------------------------------------------
Last Update Date | 04/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104B CALLE MARCOS LOPEZ
-----------------------------------------------------
City | VEGA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00693-5068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-535-2550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1410 ATLANTIC DR
-----------------------------------------------------
City | RUSKIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33570-4911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-535-2550
-----------------------------------------------------
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 | 718
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------