Provider Demographics
NPI:1629367362
Name:NAZAIRE, MAXO (CRNA)
Entity type:Individual
Prefix:
First Name:MAXO
Middle Name:
Last Name:NAZAIRE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5257 NW 109TH LN
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2755
Mailing Address - Country:US
Mailing Address - Phone:954-255-7820
Mailing Address - Fax:
Practice Address - Street 1:3601 W COMMERCIAL BLVD
Practice Address - Street 2:STE 4-5
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-3300
Practice Address - Country:US
Practice Address - Phone:954-485-5666
Practice Address - Fax:954-484-1651
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9198189367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9198189OtherLICENSE
FL003388300Medicaid
FLEV242WMedicare PIN