Provider Demographics
NPI:1114418878
Name:VIVANCO, IVAN (APRN)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:VIVANCO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:305-436-1563
Mailing Address - Fax:305-436-1564
Practice Address - Street 1:9655 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2973
Practice Address - Country:US
Practice Address - Phone:305-436-1563
Practice Address - Fax:305-436-1564
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9455497363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104828000Medicaid