Provider Demographics
NPI:1295235984
Name:MODESTO, JON ALVIN REIGO DE DIOS (RN)
Entity type:Individual
Prefix:
First Name:JON ALVIN
Middle Name:REIGO DE DIOS
Last Name:MODESTO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 SAWGRASS CORPORATE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2869
Mailing Address - Country:US
Mailing Address - Phone:954-228-7521
Mailing Address - Fax:
Practice Address - Street 1:1580 SAWGRASS CORPORATE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2869
Practice Address - Country:US
Practice Address - Phone:954-228-7521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95118046163W00000X
NMRN-85497163W00000X
TX884244163W00000X
MARN2320628163W00000X
AZRN205182163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse