Basic Information
Provider Information | |||||||||
NPI: | 1205187234 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | QUAN VIE | ||||||||
FirstName: | GISELLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LIE-TEN-SOENG | ||||||||
OtherFirstName: | GISELLE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 8181 NW 154TH ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | MIAMI LAKES | ||||||||
State: | FL | ||||||||
PostalCode: | 330165861 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055583724 | ||||||||
FaxNumber: | 7869074485 | ||||||||
Practice Location | |||||||||
Address1: | 1190 NW 95TH ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331502064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056912550 | ||||||||
FaxNumber: | 3056964610 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2012 | ||||||||
LastUpdateDate: | 08/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9106643 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | PA9106643 | 01 | FL | FLORIDA LICENSE NUMBER | OTHER |