MEDICARE: MARICELA DIANEXI FARDALES 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	363AM0700X	Medical Physician Assistant	PA9103093	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	:	1457362410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARICELA DIANEXI FARDALES PA

Provider Business Mailing Address
First Line	:	8051 W 24TH AVE STE 9
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-5596
Country	:	US
Telephone Number	:	305-400-9702
Fax Number	:	305-735-7542

Provider Business Practice Location Address
First Line	:	8051 W 24TH AVE STE 9
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-5596
Country	:	US
Telephone Number	:	305-400-9702
Fax Number	:	305-735-7542

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	07/13/2021

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