Provider Demographics
NPI:1730846221
Name:RUIZ NICOLI, FEDERICO
Entity type:Individual
Prefix:
First Name:FEDERICO
Middle Name:
Last Name:RUIZ NICOLI
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 1:10470 SW CLYDESDALE PL
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5251
Mailing Address - Country:US
Mailing Address - Phone:971-208-8359
Mailing Address - Fax:
Practice Address - Street 1:1521 CALLE ESPADACHIN, EL LEGADO GOLF RESORT
Practice Address - Street 2:APT 1521
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:971-208-8359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22574208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice