Provider Demographics
NPI:1033534433
Name:ROQUETA, LUIS MARIANO SR (SURGICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:MARIANO
Last Name:ROQUETA
Suffix:SR
Gender:M
Credentials:SURGICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 NW 95TH ST
Mailing Address - Street 2:STE # 306
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33150-2063
Mailing Address - Country:US
Mailing Address - Phone:305-693-0000
Mailing Address - Fax:
Practice Address - Street 1:1190 NW 95TH ST
Practice Address - Street 2:STE # 306
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-2063
Practice Address - Country:US
Practice Address - Phone:305-693-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-22
Last Update Date:2014-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13-486246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant