Provider Demographics
NPI:1174678775
Name:ROA, LUIS FERNANDO (PT)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:ROA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11300 NW 87TH CT
Mailing Address - Street 2:SUITE 157
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4586
Mailing Address - Country:US
Mailing Address - Phone:786-762-3915
Mailing Address - Fax:786-762-3916
Practice Address - Street 1:11300 NW 87TH CT
Practice Address - Street 2:SUITE 157
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4586
Practice Address - Country:US
Practice Address - Phone:786-762-3915
Practice Address - Fax:786-762-3916
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT22682OtherSTATE LICENSE NUMBER