Provider Demographics
NPI:1477700722
Name:REYES, MARIO ADRIAN (AGPCNP-C)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ADRIAN
Last Name:REYES
Suffix:
Gender:M
Credentials:AGPCNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 NW 27TH AVE
Mailing Address - Street 2:130
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-2157
Mailing Address - Country:US
Mailing Address - Phone:305-635-7710
Mailing Address - Fax:305-637-8122
Practice Address - Street 1:1490 NW 27TH AVE
Practice Address - Street 2:130
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-2157
Practice Address - Country:US
Practice Address - Phone:305-635-7710
Practice Address - Fax:305-637-8122
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9316143363LG0600X, 363LA2200X
FL02-128246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant