Provider Demographics
NPI:1437700093
Name:DE LA RUA, MIGUEL A (GERONTOLOGY APRN)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:DE LA RUA
Suffix:
Gender:M
Credentials:GERONTOLOGY APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2057 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322-3936
Mailing Address - Country:US
Mailing Address - Phone:954-983-9191
Mailing Address - Fax:
Practice Address - Street 1:2057 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33322-3936
Practice Address - Country:US
Practice Address - Phone:954-983-9191
Practice Address - Fax:954-422-9538
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004260363LG0600X
FLRN9483054363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAG09190084OtherAANPCB CERTIFICATION NUMBER FLORIDA BOARD OF NURSING
FLL0456OtherMEDICARE