Provider Demographics
NPI:1841797842
Name:VICTORIO, ISABELO IAN DOMINGO (ARNP)
Entity Type:Individual
Prefix:
First Name:ISABELO IAN
Middle Name:DOMINGO
Last Name:VICTORIO
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:IAN
Other - Middle Name:DOMINGO
Other - Last Name:VICTORIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2208 FRANCIS LEWIS CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4801 S UNIVERSITY DR STE 104
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3835
Practice Address - Country:US
Practice Address - Phone:954-707-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-07
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9415884363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner