Provider Demographics
NPI:1326682303
Name:PEDRERA, CARLOS ALBERTO (PTA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ALBERTO
Last Name:PEDRERA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 W 2ND CT APT 113
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6701
Mailing Address - Country:US
Mailing Address - Phone:786-991-5779
Mailing Address - Fax:
Practice Address - Street 1:5021 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3833
Practice Address - Country:US
Practice Address - Phone:305-558-1203
Practice Address - Fax:305-558-1213
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29814225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty