Basic Information
| Provider Information | |||||||||
| NPI: | 1629619978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTOLIS | ||||||||
| FirstName: | ANDREAS | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5911 SE CROOKED OAK AVE | ||||||||
| Address2: | |||||||||
| City: | HOBE SOUND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334558311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612812949 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 45TH ST | ||||||||
| Address2: | |||||||||
| City: | MANGONIA PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618446300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2019 | ||||||||
| LastUpdateDate: | 12/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/27/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11004500 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WE0003X | 9244279 | FL | N | Nursing Service Providers | Registered Nurse | Emergency |
No ID Information.