Provider Demographics
NPI:1669157442
Name:MARRERO, LUIS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:MARRERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:ENRIQUE
Other - Last Name:BUENO MARRERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2217 NORTH BLVD W
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-8990
Mailing Address - Country:US
Mailing Address - Phone:863-421-3456
Mailing Address - Fax:
Practice Address - Street 1:2217 NORTH BLVD W
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8990
Practice Address - Country:US
Practice Address - Phone:863-421-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026280363LG0600X
FLAPRN11026280363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology