Basic Information
| Provider Information | |||||||||
| NPI: | 1104221027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIGNOLE | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| OtherLastName: | FIGNOLE | ||||||||
| OtherFirstName: | GREGORY | ||||||||
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| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13300 SW 216 STREET | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052535100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13300 SW 216 STREET | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052535100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP 9366142 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | ARNP9366142 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 014300900 | 05 | FL | MEDICAID |