Provider Demographics
NPI:1235742776
Name:VICTORERO, JOSE LUIS SR (APRN)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:LUIS
Last Name:VICTORERO
Suffix:SR
Gender:M
Credentials:APRN
Other - Prefix:DR
Other - First Name:JOSE
Other - Middle Name:LUIS
Other - Last Name:VICTORERO
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:602 W 65TH DR
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6559
Mailing Address - Country:US
Mailing Address - Phone:786-314-1361
Mailing Address - Fax:
Practice Address - Street 1:702 SW 57TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-3922
Practice Address - Country:US
Practice Address - Phone:305-265-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008713363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47-5293286OtherIRS