Provider Demographics
NPI:1164290060
Name:CABAN, CARMEN A
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:A
Last Name:CABAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13742 VISTA DEL LAGO BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8044
Mailing Address - Country:US
Mailing Address - Phone:352-530-0432
Mailing Address - Fax:
Practice Address - Street 1:13742 VISTA DEL LAGO BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8044
Practice Address - Country:US
Practice Address - Phone:352-530-0432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC152101628490172A00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver