Healthcare Provider Details

I. General information

NPI: 1295611630
Provider Name (Legal Business Name): JUSTIN COLE REKIETA CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

41 TANNER TRL
SAINT AUGUSTINE FL
32092-3254
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8610
  • Fax:
Mailing address:
  • Phone: 405-200-7861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA1156
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: