Basic Information
| Provider Information | |||||||||
| NPI: | 1063710549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTEQUERA | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | PO BOX 016960 (M851) | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052437688 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1475 NW 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052438644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2011 | ||||||||
| LastUpdateDate: | 03/16/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 9105769 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA 9105769 | 01 | FL | PHYSICIAN ASSISTANT | OTHER |