Provider Demographics
NPI:1013115120
Name:HEREDIA, MARIO (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIO
Other - Middle Name:ALFREDO
Other - Last Name:HEREDIA BLANCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3127 W HALLANDALE BEACH BLVD
Mailing Address - Street 2:#102
Mailing Address - City:HALLANDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33009-5150
Mailing Address - Country:US
Mailing Address - Phone:866-816-7846
Mailing Address - Fax:954-458-2928
Practice Address - Street 1:711 E ALTAMONTE DR STE 210
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4824
Practice Address - Country:US
Practice Address - Phone:407-303-5452
Practice Address - Fax:407-303-5448
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant