Provider Demographics
NPI:1144771049
Name:RUIZ, FREDY (PA)
Entity Type:Individual
Prefix:
First Name:FREDY
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 NW 99TH PL
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1046
Mailing Address - Country:US
Mailing Address - Phone:786-261-8763
Mailing Address - Fax:
Practice Address - Street 1:3211 PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-7274
Practice Address - Country:US
Practice Address - Phone:305-443-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109956363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical