Provider Demographics
NPI:1811428980
Name:N/A
Entity type:Organization
Organization Name:N/A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERERA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:786-333-5933
Mailing Address - Street 1:6045 SW 162ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-5805
Mailing Address - Country:US
Mailing Address - Phone:786-333-5933
Mailing Address - Fax:
Practice Address - Street 1:6045 SW 162ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5805
Practice Address - Country:US
Practice Address - Phone:786-333-5933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9255335363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty