Provider Demographics
NPI:1336811165
Name:QUINONES, IVO LAZARO (PA-C)
Entity Type:Individual
Prefix:
First Name:IVO
Middle Name:LAZARO
Last Name:QUINONES
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 1:5555 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2513
Mailing Address - Country:US
Mailing Address - Phone:305-284-9100
Mailing Address - Fax:
Practice Address - Street 1:5555 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2513
Practice Address - Country:US
Practice Address - Phone:305-284-9100
Practice Address - Fax:305-284-4098
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115065363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113137200Medicaid