Provider Demographics
NPI:1902470131
Name:CORONADO, EDUILMER
Entity Type:Individual
Prefix:
First Name:EDUILMER
Middle Name:
Last Name:CORONADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 PORTER RD STE 205
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8915
Mailing Address - Country:US
Mailing Address - Phone:321-843-5851
Mailing Address - Fax:321-842-1611
Practice Address - Street 1:17000 PORTER RD STE 205
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-8915
Practice Address - Country:US
Practice Address - Phone:321-843-5851
Practice Address - Fax:321-842-1611
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11013109363LF0000X
FLAPRN11013109363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily