Provider Demographics
NPI:1780292813
Name:QUEZADA, WILDER XAVIER
Entity type:Individual
Prefix:
First Name:WILDER
Middle Name:XAVIER
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 NW 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-1939
Mailing Address - Country:US
Mailing Address - Phone:786-548-6698
Mailing Address - Fax:
Practice Address - Street 1:1412 NW 31ST AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1939
Practice Address - Country:US
Practice Address - Phone:786-548-6698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLQ2308999812702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer