Provider Demographics
NPI:1225639180
Name:BOULART, LUIS L
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:L
Last Name:BOULART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9725 NW 117TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1260
Mailing Address - Country:US
Mailing Address - Phone:954-514-9360
Mailing Address - Fax:
Practice Address - Street 1:9725 NW 117TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEDLEY
Practice Address - State:FL
Practice Address - Zip Code:33178-1260
Practice Address - Country:US
Practice Address - Phone:954-514-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008799363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11008799OtherLICENSE