Provider Demographics
NPI:1497412787
Name:EVANGELISTA, DELIO
Entity Type:Individual
Prefix:
First Name:DELIO
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DELIO
Other - Middle Name:
Other - Last Name:EVANGELISTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3765 SW 90TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-7620
Mailing Address - Country:US
Mailing Address - Phone:305-763-2309
Mailing Address - Fax:
Practice Address - Street 1:1400 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1003
Practice Address - Country:US
Practice Address - Phone:305-325-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-21
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY831259163W00000X, 367500000X
NY137202367500000X
FLAPRN11029854367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse