Provider Demographics
NPI:1902048689
Name:JOSE, REGINE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:REGINE
Middle Name:
Last Name:JOSE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17417 SW 36TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1618
Mailing Address - Country:US
Mailing Address - Phone:954-980-4127
Mailing Address - Fax:
Practice Address - Street 1:901 S STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-4522
Practice Address - Country:US
Practice Address - Phone:954-797-2900
Practice Address - Fax:954-792-4601
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104857363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical