Provider Demographics
NPI:1497881692
Name:RUIZ, ENRIQUE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:
Last Name:RUIZ
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 1:632 DEL PRADO BLVD N
Mailing Address - Street 2:STE 201
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-2278
Mailing Address - Country:US
Mailing Address - Phone:239-829-7102
Mailing Address - Fax:
Practice Address - Street 1:632 DEL PRADO BLVD N
Practice Address - Street 2:STE 201
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2278
Practice Address - Country:US
Practice Address - Phone:239-829-7102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104245363A00000X
NC0010-00772363A00000X
FLPA91042445363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAI687VMedicare PIN