Provider Demographics
NPI:1366021057
Name:PEDRAJA FUENTES, BANIA
Entity Type:Individual
Prefix:
First Name:BANIA
Middle Name:
Last Name:PEDRAJA FUENTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 NW 183RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-2929
Mailing Address - Country:US
Mailing Address - Phone:786-985-1635
Mailing Address - Fax:
Practice Address - Street 1:9250 NW 36TH ST STE 420
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2775
Practice Address - Country:US
Practice Address - Phone:305-266-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty