Provider Demographics
NPI:1568447829
Name:DE LA PORTILLA, MARIO LUIS (CRNA)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:LUIS
Last Name:DE LA PORTILLA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840207
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33084-2207
Mailing Address - Country:US
Mailing Address - Phone:305-595-4510
Mailing Address - Fax:
Practice Address - Street 1:9370 SUNSET DR
Practice Address - Street 2:SUITE A-250
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-5431
Practice Address - Country:US
Practice Address - Phone:305-595-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9166474367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered