Provider Demographics
NPI:1992022602
Name:BRACERO, MARCOS ALFONSO (ARNP)
Entity Type:Individual
Prefix:MR
First Name:MARCOS
Middle Name:ALFONSO
Last Name:BRACERO
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 NW MILNER DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3392
Mailing Address - Country:US
Mailing Address - Phone:772-873-4954
Mailing Address - Fax:772-873-4954
Practice Address - Street 1:5150 NW MILNER DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-3392
Practice Address - Country:US
Practice Address - Phone:772-873-4954
Practice Address - Fax:772-873-4954
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9191326363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004715200Medicaid
FLARNP9191326OtherARNP ID
FLEE239YMedicare PIN