Provider Demographics
NPI:1912943614
Name:ROMERO, JUAN C (PA)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:ROMERO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8750 NW 36TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2499
Mailing Address - Country:US
Mailing Address - Phone:305-262-1610
Mailing Address - Fax:305-907-6099
Practice Address - Street 1:4218 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-2306
Practice Address - Country:US
Practice Address - Phone:305-266-2929
Practice Address - Fax:786-558-9980
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9101558OtherPHYSICIAN ASST LICENSE
FLPA9101558OtherPHYSICIAN ASST LICENSE
FLQ02696Medicare UPIN