Basic Information
| Provider Information | |||||||||
| NPI: | 1457853483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACOSTA GARAYUA | ||||||||
| FirstName: | PABLO | ||||||||
| MiddleName: | OMAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | HC 4 BOX 11946 | ||||||||
| Address2: | |||||||||
| City: | YAUCO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006989608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874504980 | ||||||||
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| Practice Location | |||||||||
| Address1: | PO BOX 365067 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009365067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582525 | ||||||||
| FaxNumber: | 7877540710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2018 | ||||||||
| LastUpdateDate: | 03/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 32986-R | PR | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 32986-R | 01 | PR | MEDICAL LISCENCE | OTHER |