MEDICARE: EDGAR R PERALTA-LEE APRN

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	363LF0000X	Family Nurse Practitioner	APRN11038681	FL

General Provider Information

NPI Number	:	1841086881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDGAR R PERALTA-LEE APRN

Provider Business Mailing Address
First Line	:	1412 SW 158TH AVE
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33027-2368
Country	:	US
Telephone Number	:	347-606-5911
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 NW 183RD ST STE 204
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-4578
Country	:	US
Telephone Number	:	305-655-0702
Fax Number	:	305-655-0845

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

Provider Enumeration Date	:	04/16/2025
Last Update Date	:	04/16/2025

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