Provider Demographics
NPI:1679767941
Name:DE OLEO, JUAN MANUEL (PA)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MANUEL
Last Name:DE OLEO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NW 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-4000
Mailing Address - Country:US
Mailing Address - Phone:305-642-3724
Mailing Address - Fax:
Practice Address - Street 1:600 NW 35TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-4000
Practice Address - Country:US
Practice Address - Phone:305-642-3724
Practice Address - Fax:305-643-2228
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant