Provider Demographics
NPI:1902600513
Name:ENRIQUEZ, EDIEL (PA)
Entity type:Individual
Prefix:
First Name:EDIEL
Middle Name:
Last Name:ENRIQUEZ
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10450 SW 157TH CT APT 206
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-3649
Mailing Address - Country:US
Mailing Address - Phone:305-710-4777
Mailing Address - Fax:
Practice Address - Street 1:5 CALLE BARBOSA
Practice Address - Street 2:
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662-2956
Practice Address - Country:US
Practice Address - Phone:939-313-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR002512363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical