Provider Demographics
NPI:1356942031
Name:ULLOA CAPESTANY, JORGE LUIS (APRN)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:ULLOA CAPESTANY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6865 W 7TH AVE APT 408
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4877
Mailing Address - Country:US
Mailing Address - Phone:786-307-2572
Mailing Address - Fax:
Practice Address - Street 1:6865 W 7TH AVE APT 408
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4877
Practice Address - Country:US
Practice Address - Phone:786-307-2572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010052363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner