Provider Demographics
NPI:1003904699
Name:RECIO, ALTAGRACIA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:ALTAGRACIA
Middle Name:
Last Name:RECIO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SW 27TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135
Mailing Address - Country:US
Mailing Address - Phone:305-642-3396
Mailing Address - Fax:305-642-6622
Practice Address - Street 1:701 SW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-3031
Practice Address - Country:US
Practice Address - Phone:305-642-3396
Practice Address - Fax:305-642-6622
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9101967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291288100Medicaid