Provider Demographics
NPI:1922785245
Name:TAVERAS, LUIS ARMANDO (PA)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ARMANDO
Last Name:TAVERAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 TALISI LOOP
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-9162
Mailing Address - Country:US
Mailing Address - Phone:407-961-9002
Mailing Address - Fax:
Practice Address - Street 1:324 TALISI LOOP
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34771-9162
Practice Address - Country:US
Practice Address - Phone:407-961-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
PR1500PA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program