Basic Information
Provider Information
NPI: 1790269777
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FERNANDEZ-QUILES
FirstName: MIGUEL
MiddleName: ANDRES
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 30236
Address2:  
City: SAN JUAN
State: PR
PostalCode: 009291236
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: AV AMERICO MIRANDA S/N
Address2:  
City: SAN JUAN
State: PR
PostalCode: 009350001
CountryCode: US
TelephoneNumber: 7877773535
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/17/2018
LastUpdateDate: 09/17/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1744R1102X6237085PRY Other Service ProvidersSpecialistResearch Study

No ID Information.


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