Provider Demographics
NPI:1801473103
Name:QUEROL MATOS, WILFREDO ANDRES
Entity type:Individual
Prefix:
First Name:WILFREDO
Middle Name:ANDRES
Last Name:QUEROL MATOS
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 1:1400 NW 107TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2746
Mailing Address - Country:US
Mailing Address - Phone:305-534-0076
Mailing Address - Fax:
Practice Address - Street 1:551 E 49TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-1904
Practice Address - Country:US
Practice Address - Phone:305-534-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11012199363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN9932OtherMEDICARE