Provider Demographics
NPI:1063656155
Name:CONVENIENT PRACTITIONER SERVICES PA
Entity Type:Organization
Organization Name:CONVENIENT PRACTITIONER SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:IGDALIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLDAN CHRISTEN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:954-861-7522
Mailing Address - Street 1:10641 SW 37TH PL
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1310
Mailing Address - Country:US
Mailing Address - Phone:954-861-7522
Mailing Address - Fax:954-916-9436
Practice Address - Street 1:10641 SW 37TH PL
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-1310
Practice Address - Country:US
Practice Address - Phone:954-861-7522
Practice Address - Fax:954-916-9436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1737192207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS51924Medicare UPIN