Provider Demographics
NPI:1326594755
Name:LIBERA, MIGUEL M (PA)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:M
Last Name:LIBERA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6750 SW 156TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2125
Mailing Address - Country:US
Mailing Address - Phone:786-303-0985
Mailing Address - Fax:
Practice Address - Street 1:11801 SW 90TH ST STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-2182
Practice Address - Country:US
Practice Address - Phone:305-595-1317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9109707363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant