Provider Demographics
NPI:1164109112
Name:GARCIA, IVAN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:GARCIA
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 SW 149TH AVE APT 1203
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1444
Mailing Address - Country:US
Mailing Address - Phone:787-601-7887
Mailing Address - Fax:
Practice Address - Street 1:8500 SW 149TH AVE APT 1203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1444
Practice Address - Country:US
Practice Address - Phone:787-601-7887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001423-PA363A00000X
001423-PA363AM0700X
PR001423363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical