Provider Demographics
NPI:1023290269
Name:MENNIG SAN ROMAN, JOHAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHAN
Middle Name:
Last Name:MENNIG SAN ROMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6634 SW 114TH PL
Mailing Address - Street 2:UNIT A
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-1783
Mailing Address - Country:US
Mailing Address - Phone:305-793-4706
Mailing Address - Fax:
Practice Address - Street 1:975 BAPTIST WAY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7600
Practice Address - Country:US
Practice Address - Phone:305-793-4706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3409363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical