Provider Demographics
NPI:1720192156
Name:MOTA, RAFAEL DEJESUS (PA)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:DEJESUS
Last Name:MOTA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15483 SW 12 TERRACE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33194
Mailing Address - Country:US
Mailing Address - Phone:305-266-0135
Mailing Address - Fax:786-556-9900
Practice Address - Street 1:3940 W FLAGLER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1613
Practice Address - Country:US
Practice Address - Phone:786-566-9900
Practice Address - Fax:305-266-0135
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9100826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ63087Medicare UPIN