Provider Demographics
NPI:1265191803
Name:MUJICA, CARLOS MARIO (APRN)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:MARIO
Last Name:MUJICA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6747 RALSTON BEACH CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-4207
Mailing Address - Country:US
Mailing Address - Phone:813-580-2268
Mailing Address - Fax:
Practice Address - Street 1:13302 WINDING OAK CT STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-3425
Practice Address - Country:US
Practice Address - Phone:813-930-8424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11016795363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty