Provider Demographics
NPI:1689978843
Name:TAVERAS, MILDRED (PA)
Entity Type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:
Last Name:TAVERAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12177 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-1727
Mailing Address - Country:US
Mailing Address - Phone:954-436-0555
Mailing Address - Fax:954-433-0108
Practice Address - Street 1:12177 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-1727
Practice Address - Country:US
Practice Address - Phone:954-436-0555
Practice Address - Fax:954-436-0108
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant