1437700093 NPI number — MIGUEL A DE LA RUA GERONTOLOGY APRN

Table of content: MIGUEL A DE LA RUA GERONTOLOGY APRN (NPI 1437700093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437700093 NPI number — MIGUEL A DE LA RUA GERONTOLOGY APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA RUA
Provider First Name:
MIGUEL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
GERONTOLOGY APRN
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:
1437700093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2057 N UNIVERSITY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33322-3936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-983-9191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2057 N UNIVERSITY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNRISE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33322-3936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-983-9191
Provider Business Practice Location Address Fax Number:
954-422-9538
Provider Enumeration Date:
09/25/2019

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: 363LG0600X , with the licence number:  APRN11004260 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LG0600X , with the licence number: RN9483054 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: AG09190084 . This is a "AANPCB CERTIFICATION NUMBER FLORIDA BOARD OF NURSING" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: L0456 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 106688200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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