1700852522 NPI number — CARLOS NICOLAS CASO PA-C

Table of content: GAI LEIGH CLEMMER ATC (NPI 1881725448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700852522 NPI number — CARLOS NICOLAS CASO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASO
Provider First Name:
CARLOS
Provider Middle Name:
NICOLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700852522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 SAN REMO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL GABLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33146-3043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-595-3711
Provider Business Mailing Address Fax Number:
786-533-9556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
COUNTRY WALK URGENT CARE EXPRESS
Provider Second Line Business Practice Location Address:
15721 SW 152ND ST
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33187-1347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-595-3711
Provider Business Practice Location Address Fax Number:
786-533-9556
Provider Enumeration Date:
02/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9112159 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA10004439 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA9112159 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 109285100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".