Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0103X | Foot & Ankle Surgery | PO3002 | FL |
NPI | 1033195979 |
---|---|
Provider Name | Ryan J Pereira |
First Address | St Augustine, FL 32080-3108 |
Second Address | St Augustine, FL 32080-3108 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2005 |
Last Update Date | 13/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
340356400 | (05) | FL |
65756 | BCBS (01) | FL |
U92103 | (02) |