Provider Demographics
NPI:1518546142
Name:FAJARDO, ALVARO
Entity Type:Individual
Prefix:
First Name:ALVARO
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 SW JAMESPORT DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-4355
Mailing Address - Country:US
Mailing Address - Phone:305-479-4677
Mailing Address - Fax:
Practice Address - Street 1:1720 SW JAMESPORT DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-4355
Practice Address - Country:US
Practice Address - Phone:305-479-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11010534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily