Provider Demographics
NPI:1710099213
Name:GALIANO-CEVALLOS, MARIO IVAN (PA)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:IVAN
Last Name:GALIANO-CEVALLOS
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 1:4469 S CONGRESS AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4726
Mailing Address - Country:US
Mailing Address - Phone:561-642-0768
Mailing Address - Fax:561-642-0769
Practice Address - Street 1:4469 S CONGRESS AVE STE 106
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-4726
Practice Address - Country:US
Practice Address - Phone:561-642-0768
Practice Address - Fax:561-642-0769
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100820363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291336400Medicaid
FL93642Medicare ID - Type Unspecified