Provider Demographics
NPI:1043328263
Name:MENCHAVEZ, ANTONIO B (CRNA)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:B
Last Name:MENCHAVEZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7520
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-7520
Mailing Address - Country:US
Mailing Address - Phone:772-335-2471
Mailing Address - Fax:772-335-2497
Practice Address - Street 1:1800 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7521
Practice Address - Country:US
Practice Address - Phone:772-335-2471
Practice Address - Fax:772-335-2497
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1349432163WM0705X
FLARNP1349432367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG0704YMedicare ID - Type Unspecified