Provider Demographics
NPI:1134998800
Name:FORTUN PLANE, PRIMITIVO (APRN)
Entity type:Individual
Prefix:
First Name:PRIMITIVO
Middle Name:
Last Name:FORTUN PLANE
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 1:777 E 25TH ST STE 508
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3834
Mailing Address - Country:US
Mailing Address - Phone:305-696-7772
Mailing Address - Fax:305-696-8556
Practice Address - Street 1:777 E 25TH ST STE 508
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3834
Practice Address - Country:US
Practice Address - Phone:305-696-7772
Practice Address - Fax:305-696-8556
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11029973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily