Provider Demographics
NPI:1912270554
Name:REGUEIFEROS, RAFAEL JR (PA-C)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:REGUEIFEROS
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10743 NARCOOSSEE RD
Mailing Address - Street 2:SUITE A-18
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832
Mailing Address - Country:US
Mailing Address - Phone:407-427-7190
Mailing Address - Fax:407-277-1888
Practice Address - Street 1:10743 NARCOOSSEE RD
Practice Address - Street 2:SUITE A-18
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-5781
Practice Address - Country:US
Practice Address - Phone:407-277-1900
Practice Address - Fax:407-277-1888
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106410363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9106410OtherFLORIDA LICENSE
FLGK942XMedicare PIN