Provider Demographics
NPI:1396179255
Name:RODRIGUEZ, JESUS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JESUS
Middle Name:
Last Name:RODRIGUEZ
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 1:10095 N KENDALL DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1797
Mailing Address - Country:US
Mailing Address - Phone:305-595-5455
Mailing Address - Fax:
Practice Address - Street 1:10095 N KENDALL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1797
Practice Address - Country:US
Practice Address - Phone:305-595-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107378363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1396179255OtherNPI