MEDICARE: MR. WICKANDER FERREIRA MLT (ASCP)CM

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	246RM2200X	Medical Laboratory Technician		FL
2	246Q00000X	Pathology Specialist/Technologist	TC52623	FL

General Provider Information

NPI Number	:	1972009066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WICKANDER FERREIRA MLT (ASCP)CM

Provider Business Mailing Address
First Line	:	18100 W DIXIE HWY STE 205
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33160-2059
Country	:	US
Telephone Number	:	305-704-8503
Fax Number	:

Provider Business Practice Location Address
First Line	:	18100 W DIXIE HWY STE 205
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33160-2059
Country	:	US
Telephone Number	:	305-704-8503
Fax Number	:

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

Provider Enumeration Date	:	04/05/2018
Last Update Date	:	08/06/2024

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