Provider Demographics
NPI:1679196695
Name:FRAGA, LEOSVEL
Entity Type:Individual
Prefix:
First Name:LEOSVEL
Middle Name:
Last Name:FRAGA
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 1:4110 SW 107TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-4821
Mailing Address - Country:US
Mailing Address - Phone:305-781-4650
Mailing Address - Fax:
Practice Address - Street 1:8900 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2118
Practice Address - Country:US
Practice Address - Phone:786-596-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA594367H00000X
367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant