MEDICARE: MAYARA DE LOURDES TORRES RODRIGUEZ

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	20230220120815	WA

General Provider Information

NPI Number	:	1780430900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYARA DE LOURDES TORRES RODRIGUEZ

Provider Business Mailing Address
First Line	:	457 NW 57TH AVE APT 30N
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-4848
Country	:	US
Telephone Number	:	786-519-9802
Fax Number	:

Provider Business Practice Location Address
First Line	:	457 NW 57TH AVE APT 30N
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-4848
Country	:	US
Telephone Number	:	786-519-9802
Fax Number	:

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

Provider Enumeration Date	:	04/29/2024
Last Update Date	:	04/29/2024

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