Basic Information
| Provider Information | |||||||||
| NPI: | 1619487659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | ERNESTO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEREZ GRACIA | ||||||||
| OtherFirstName: | JOEL | ||||||||
| OtherMiddleName: | ERNESTO | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12171 SW 268TH ST | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330328001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052780200 | ||||||||
| FaxNumber: | 7864301583 | ||||||||
| Practice Location | |||||||||
| Address1: | 8726 W WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336151714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137121726 | ||||||||
| FaxNumber: | 8139254640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2017 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9397644 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.