Provider Demographics
NPI:1104441161
Name:QUINTANA MARTINEZ, MARIO IGNACIO (APRN)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:IGNACIO
Last Name:QUINTANA MARTINEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 W 56TH ST APT 2320
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4765
Mailing Address - Country:US
Mailing Address - Phone:786-210-3860
Mailing Address - Fax:
Practice Address - Street 1:315 W 9TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-3853
Practice Address - Country:US
Practice Address - Phone:786-360-4528
Practice Address - Fax:786-360-4529
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11006342363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ535549622711OtherDRIVERS LICENSE