Provider Demographics
NPI:1043459563
Name:ULLOA, FERNANDO M (APRN)
Entity type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:M
Last Name:ULLOA
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:PO BOX 350137
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-0137
Mailing Address - Country:US
Mailing Address - Phone:718-721-1674
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 350137
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32135-0137
Practice Address - Country:US
Practice Address - Phone:718-721-1674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY574074-1163W00000X
FLRN9623430163W00000X
FLAPRN11025366363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse