Provider Demographics
NPI:1639871866
Name:REGALADO RODRIGUEZ, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:REGALADO RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:IVAN
Other - Middle Name:
Other - Last Name:REGALADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4614 WISTERIA LN
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-6986
Mailing Address - Country:US
Mailing Address - Phone:770-882-1728
Mailing Address - Fax:
Practice Address - Street 1:4614 WISTERIA LN
Practice Address - Street 2:
Practice Address - City:FORTSON
Practice Address - State:GA
Practice Address - Zip Code:31808-6986
Practice Address - Country:US
Practice Address - Phone:770-882-1728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11025390363LF0000X
GARN291972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily