Basic Information
| Provider Information | |||||||||
| NPI: | 1164792834 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | MIGUEL | ||||||||
| MiddleName: | ANGEL | ||||||||
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| Credential: | APRN-NA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 GOLDSBORO RD 400 | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208175846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012630800 | ||||||||
| FaxNumber: | 3012630820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1968 PEACHTREE RD NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782160771 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2012 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN277715 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AC001375 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 7100200480 | 05 | KY | MEDICAID | 201109950A | 05 | IN | MEDICAID |