MEDICARE: SERGIO JAVIER GARDEAZABAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	11007982	FL

General Provider Information

NPI Number	:	1003416561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERGIO JAVIER GARDEAZABAL

Provider Business Mailing Address
First Line	:	11039 W OKEECHOBEE RD UNIT 201
Second Line	:
City	:	HIALEAH GARDENS
State	:	FL
Zip	:	33018-4256
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11039 W OKEECHOBEE RD UNIT 201
Second Line	:
City	:	HIALEAH GARDENS
State	:	FL
Zip	:	33018-4256
Country	:	US
Telephone Number	:	786-630-5957
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2020
Last Update Date	:	10/26/2020

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