Provider Demographics
NPI:1891179131
Name:MONTILLA OLIVARES, NIXON JOANNY (SA-C)
Entity Type:Individual
Prefix:
First Name:NIXON
Middle Name:JOANNY
Last Name:MONTILLA OLIVARES
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 E 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-3205
Mailing Address - Country:US
Mailing Address - Phone:305-499-0122
Mailing Address - Fax:
Practice Address - Street 1:1541 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-3205
Practice Address - Country:US
Practice Address - Phone:305-499-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15-355246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant