Provider Demographics
NPI:1124634464
Name:AMEZQUITA, MARCELINO
Entity type:Individual
Prefix:
First Name:MARCELINO
Middle Name:
Last Name:AMEZQUITA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARCELINO
Other - Middle Name:
Other - Last Name:AMEZQUITA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:10250 SW 56TH ST STE C101
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-7065
Mailing Address - Country:US
Mailing Address - Phone:786-558-8901
Mailing Address - Fax:
Practice Address - Street 1:10250 SW 56TH ST STE C101
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-7065
Practice Address - Country:US
Practice Address - Phone:135-257-5570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009130363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner