Provider Demographics
NPI:1063070340
Name:MASTROMARINO, ELISA N
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:N
Last Name:MASTROMARINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1119
Mailing Address - Country:US
Mailing Address - Phone:305-326-6543
Mailing Address - Fax:305-326-6563
Practice Address - Street 1:900 NW 17TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1119
Practice Address - Country:US
Practice Address - Phone:305-326-6543
Practice Address - Fax:305-326-6563
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9388755163W00000X
FLAPRN11003556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN9388768OtherREGISTERED NURSE LICENSE