MEDICARE: MISS FLOR DE MARIA CRISOLOGO PA

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	163W00000X	Registered Nurse	RN2114402	FL
2	363AM0700X	Medical Physician Assistant	PA9100393	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	:	1306816327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS FLOR DE MARIA CRISOLOGO PA

Provider Business Mailing Address
First Line	:	209 NE 95TH ST
Second Line	:	SUITE 9
City	:	MIAMI SHORES
State	:	FL
Zip	:	33138-2745
Country	:	US
Telephone Number	:	305-751-5454
Fax Number	:	305-751-1977

Provider Business Practice Location Address
First Line	:	209 NE 95TH ST
Second Line	:	SUITE 9
City	:	MIAMI SHORES
State	:	FL
Zip	:	33138-2745
Country	:	US
Telephone Number	:	305-751-5454
Fax Number	:	305-751-1977

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

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	06/23/2009

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Directions to “ MISS FLOR DE MARIA CRISOLOGO PA” Practice Location

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