MEDICARE: MR. HUGO PEREZ LARA 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	PA 9100602	FL
2	363AM0700X	Medical Physician Assistant	PA9100602	FL

General Provider Information

NPI Number	:	1669636825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HUGO PEREZ LARA PA

Provider Business Mailing Address
First Line	:	12177 PEMBROKE RD
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33025-1727
Country	:	US
Telephone Number	:	954-436-0555
Fax Number	:	954-436-0108

Provider Business Practice Location Address
First Line	:	12177 PEMBROKE RD
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33025-1727
Country	:	US
Telephone Number	:	954-436-0555
Fax Number	:	954-436-0108

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

Provider Enumeration Date	:	07/16/2008
Last Update Date	:	07/29/2013

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