Provider Demographics
NPI:1275737306
Name:RENGIFO, RODNEY B (PA-C)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:B
Last Name:RENGIFO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 W 16TH AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7190
Mailing Address - Country:US
Mailing Address - Phone:786-691-1110
Mailing Address - Fax:
Practice Address - Street 1:4445 W 16TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7189
Practice Address - Country:US
Practice Address - Phone:786-691-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102557363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant