Provider Demographics
NPI:1710582713
Name:AMADOR FRAGA, ERNESTO
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:AMADOR FRAGA
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 1:6460 MAIN ST APT 311
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2261
Mailing Address - Country:US
Mailing Address - Phone:786-285-0171
Mailing Address - Fax:
Practice Address - Street 1:6460 MAIN ST APT 311
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2261
Practice Address - Country:US
Practice Address - Phone:786-285-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9476576163W00000X
FLAPRN11009731363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse