Provider Demographics
NPI:1982080099
Name:DE ARREDONDO DIAZ, JUAN CARLOS (FNP)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:DE ARREDONDO DIAZ
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11102 NW 83RD ST APT 230
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1742
Mailing Address - Country:US
Mailing Address - Phone:305-890-8763
Mailing Address - Fax:
Practice Address - Street 1:3663 S MIAMI AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4253
Practice Address - Country:US
Practice Address - Phone:305-856-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13-573246ZC0007X
FLAPRN11006151363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012833OtherFLORIDA BLUE