Provider Demographics
NPI:1215503305
Name:ROQUE BAZ, AMARILYS ROQUE
Entity type:Individual
Prefix:
First Name:AMARILYS
Middle Name:ROQUE
Last Name:ROQUE BAZ
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 1:8507 DAWN DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-7923
Mailing Address - Country:US
Mailing Address - Phone:407-556-5726
Mailing Address - Fax:
Practice Address - Street 1:121 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-3221
Practice Address - Country:US
Practice Address - Phone:407-556-5726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11013393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily