Basic Information
Provider Information | |||||||||
NPI: | 1154519932 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEDRANO | ||||||||
FirstName: | SERGIO | ||||||||
MiddleName: | RUBEN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7200 CORPORATE CENTER DR | ||||||||
Address2: | SUITE 600 | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331261200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055002009 | ||||||||
FaxNumber: | 3055002145 | ||||||||
Practice Location | |||||||||
Address1: | 11865 SW 26TH ST # A | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331752400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055002009 | ||||||||
FaxNumber: | 3055002145 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2007 | ||||||||
LastUpdateDate: | 10/05/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9101126 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.