Provider Demographics
NPI:1003142381
Name:ORTIZ, BERNARDO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BERNARDO
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17301 SW 86TH AVE
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-4672
Mailing Address - Country:US
Mailing Address - Phone:786-423-3365
Mailing Address - Fax:
Practice Address - Street 1:17301 SW 86TH AVE
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-4672
Practice Address - Country:US
Practice Address - Phone:786-423-3365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101756363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical