Basic Information
| Provider Information | |||||||||
| NPI: | 1760024871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRATIA | ||||||||
| FirstName: | VLADYMIR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 NE 125TH ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | 3058914228 | ||||||||
| Practice Location | |||||||||
| Address1: | 7481 W OAKLAND PARK BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LAUDERHILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333193331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547717743 | ||||||||
| FaxNumber: | 9547717748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2019 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 11004446 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 105098800 | 05 | FL | MEDICAID |