Healthcare Provider Details

I. General information

NPI: 1396679452
Provider Name (Legal Business Name): OMAR ROGER MAURICE DANIEL FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13681 DOCTORS WAY
FORT MYERS FL
33912-4300
US

IV. Provider business mailing address

13681 DOCTORS WAY # 4MPCU
FORT MYERS FL
33912-4300
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-1852
  • Fax: 239-343-0524
Mailing address:
  • Phone: 239-343-1852
  • Fax: 239-343-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN9440708
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: