Provider Demographics
NPI:1427776095
Name:PERDOMO SANTA CRUZ, MARIO MANUEL (RNFA)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:MANUEL
Last Name:PERDOMO SANTA CRUZ
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 BUXTON DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-2304
Mailing Address - Country:US
Mailing Address - Phone:786-675-1616
Mailing Address - Fax:
Practice Address - Street 1:4300 BUXTON DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2304
Practice Address - Country:US
Practice Address - Phone:786-675-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22-492246ZC0007X
KY1174207163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant