Provider Demographics
NPI:1780430900
Name:TORRES RODRIGUEZ, MAYARA DE LOURDES
Entity type:Individual
Prefix:
First Name:MAYARA
Middle Name:DE LOURDES
Last Name:TORRES RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 NW 57TH AVE APT 30N
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4848
Mailing Address - Country:US
Mailing Address - Phone:786-519-9802
Mailing Address - Fax:
Practice Address - Street 1:457 NW 57TH AVE APT 30N
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-4848
Practice Address - Country:US
Practice Address - Phone:786-519-9802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA20230220120815363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical