Provider Demographics
NPI:1790373090
Name:AREVALO, RICHARD EDUARDO SR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EDUARDO
Last Name:AREVALO
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14810 SW 296TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-2824
Mailing Address - Country:US
Mailing Address - Phone:786-564-2702
Mailing Address - Fax:
Practice Address - Street 1:43 NE 15TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4506
Practice Address - Country:US
Practice Address - Phone:786-243-1909
Practice Address - Fax:786-243-4292
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010693363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner