Provider Demographics
NPI:1629619978
Name:BERTOLIS, ANDREAS JOHN (RN)
Entity Type:Individual
Prefix:
First Name:ANDREAS
Middle Name:JOHN
Last Name:BERTOLIS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5911 SE CROOKED OAK AVE
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-8311
Mailing Address - Country:US
Mailing Address - Phone:561-281-2949
Mailing Address - Fax:
Practice Address - Street 1:901 45TH ST
Practice Address - Street 2:
Practice Address - City:MANGONIA PARK
Practice Address - State:FL
Practice Address - Zip Code:33407-2413
Practice Address - Country:US
Practice Address - Phone:561-844-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004500363LF0000X
FL9244279163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163WE0003XNursing Service ProvidersRegistered NurseEmergencyGroup - Single Specialty