Provider Demographics
NPI:1912474354
Name:PANEQUE, RICARDO (MSN, APRN, MT)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:PANEQUE
Suffix:
Gender:M
Credentials:MSN, APRN, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SW 109TH AVE APT C3
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1229
Mailing Address - Country:US
Mailing Address - Phone:786-619-5210
Mailing Address - Fax:
Practice Address - Street 1:11 SW 109TH AVE APT C3
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1229
Practice Address - Country:US
Practice Address - Phone:786-619-5210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-68673106S00000X
FL11006595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician