Provider Demographics
NPI:1710639257
Name:CRUZ, YILIAN
Entity Type:Individual
Prefix:MRS
First Name:YILIAN
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8254 NW 165TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-3472
Mailing Address - Country:US
Mailing Address - Phone:786-667-0070
Mailing Address - Fax:305-603-9934
Practice Address - Street 1:4634 NW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-3510
Practice Address - Country:US
Practice Address - Phone:786-275-4680
Practice Address - Fax:305-603-9934
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QP2000X, 261QP2300X
FL202204195961363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL202204195961OtherREGISTERED MEDICAL ASSISTANT
FL110254700Medicaid