Provider Demographics
NPI:1790062982
Name:BAEZ, IVAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:BAEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9940 W CALUSA CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-1512
Mailing Address - Country:US
Mailing Address - Phone:786-232-5450
Mailing Address - Fax:
Practice Address - Street 1:1150 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5424
Practice Address - Country:US
Practice Address - Phone:954-265-3437
Practice Address - Fax:954-983-5052
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9108132363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant