Healthcare Provider Details

I. General information

NPI: 1790502540
Provider Name (Legal Business Name): YAISER ROQUE APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17901 SUMMERLIN RD STE C
FORT MYERS FL
33908-5765
US

IV. Provider business mailing address

17901 SUMMERLIN RD STE C
FORT MYERS FL
33908-5765
US

V. Phone/Fax

Practice location:
  • Phone: 239-291-3602
  • Fax:
Mailing address:
  • Phone: 239-291-3602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11018860
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: