Healthcare Provider Details

I. General information

NPI: 1861025132
Provider Name (Legal Business Name): GEORGE REZKALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2292 GUADELUPE DR
NAPLES FL
34119-3349
US

IV. Provider business mailing address

2292 GUADELUPE DR
NAPLES FL
34119-3349
US

V. Phone/Fax

Practice location:
  • Phone: 918-704-8881
  • Fax:
Mailing address:
  • Phone: 918-704-8881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11007015
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9457095
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: