Provider Demographics
NPI:1114748548
Name:MAIRENA, LILIAN DANIELA (PA)
Entity type:Individual
Prefix:
First Name:LILIAN
Middle Name:DANIELA
Last Name:MAIRENA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7710 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2320
Mailing Address - Country:US
Mailing Address - Phone:772-335-5300
Mailing Address - Fax:772-200-2131
Practice Address - Street 1:7710 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2320
Practice Address - Country:US
Practice Address - Phone:772-335-5300
Practice Address - Fax:772-200-2131
Is Sole Proprietor?:No
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9119460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant