Provider Demographics
NPI:1033836929
Name:PEREZ CARRODEGUAS, MAIKEL
Entity Type:Individual
Prefix:
First Name:MAIKEL
Middle Name:
Last Name:PEREZ CARRODEGUAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RIVERFRONT BLVD STE 710
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8812
Mailing Address - Country:US
Mailing Address - Phone:941-776-4000
Mailing Address - Fax:
Practice Address - Street 1:6015 POINTE WEST BLVD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5525
Practice Address - Country:US
Practice Address - Phone:941-776-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11022614363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner