Provider Demographics
NPI:1972904324
Name:JIMENEZ, GUILLERMO JESUS (PA)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:JESUS
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10810 SW 126TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3749
Mailing Address - Country:US
Mailing Address - Phone:786-423-3357
Mailing Address - Fax:
Practice Address - Street 1:9240 SW 72ND ST STE 241
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3265
Practice Address - Country:US
Practice Address - Phone:305-271-1919
Practice Address - Fax:786-271-1911
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9108110363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical