Basic Information
| Provider Information | |||||||||
| NPI: | 1114508280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAVEZ BARRIENTOS | ||||||||
| FirstName: | MARIALICIA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 S UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542621250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2950 CLEVELAND CLINIC BLVD | ||||||||
| Address2: | |||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333313609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546595124 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2021 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9116583 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.