Provider Demographics
NPI:1487328910
Name:PERALTA PENA, JUNIOR MANUEL (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:JUNIOR
Middle Name:MANUEL
Last Name:PERALTA PENA
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 W 12TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2266
Mailing Address - Country:US
Mailing Address - Phone:786-778-0968
Mailing Address - Fax:
Practice Address - Street 1:9050 PINES BLVD STE 150
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6400
Practice Address - Country:US
Practice Address - Phone:954-872-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-07
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014221363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily