Provider Demographics
NPI:1568019982
Name:BOLANO, JOSE RAMON
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:RAMON
Last Name:BOLANO
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 1:15335 SW 54TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4114
Mailing Address - Country:US
Mailing Address - Phone:305-804-0808
Mailing Address - Fax:
Practice Address - Street 1:15335 SW 54TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-4114
Practice Address - Country:US
Practice Address - Phone:305-804-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11003721363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily