Provider Demographics
NPI:1386245652
Name:PORTILLO BARRERA, MANUEL SALVADOR (APRN)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:SALVADOR
Last Name:PORTILLO BARRERA
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 1:4383 FOXTAIL LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3842
Mailing Address - Country:US
Mailing Address - Phone:954-338-8661
Mailing Address - Fax:
Practice Address - Street 1:1950 W HILLSBORO BLVD STE 103
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-1423
Practice Address - Country:US
Practice Address - Phone:954-408-8960
Practice Address - Fax:954-408-8961
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF10201183363LF0000X
FLAPRN11010371363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily