MEDICARE: MR. JOSE ANTONIO PUERTO PHYSICIAN ASSISTANT

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	363A00000X	Physician Assistant	PA9100243	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073546933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSE ANTONIO PUERTO PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	8400 NW 33RD ST
Second Line	:	SUITE 201
City	:	DORAL
State	:	FL
Zip	:	33122-1937
Country	:	US
Telephone Number	:	786-408-8502
Fax Number	:	305-402-0855

Provider Business Practice Location Address
First Line	:	18610 NW 87TH AVE
Second Line	:	SUITE 101 AND 201
City	:	HIALEAH
State	:	FL
Zip	:	33015-3518
Country	:	US
Telephone Number	:	305-829-5000
Fax Number	:	305-829-5033

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	09/29/2016

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