MEDICARE: ENOBONG ETTANG ARNP

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	363L00000X	Nurse Practitioner	ARNP2014862	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	:	1336217314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENOBONG ETTANG ARNP

Provider Business Mailing Address
First Line	:	3090 SW 37TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33133-4311
Country	:	US
Telephone Number	:	305-351-1320
Fax Number	:	305-444-7866

Provider Business Practice Location Address
First Line	:	3090 SW 37TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33133-4311
Country	:	US
Telephone Number	:	305-351-1320
Fax Number	:	305-444-7866

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

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	02/01/2013

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