Healthcare Provider Details

I. General information

NPI: 1578021473
Provider Name (Legal Business Name): MALCOLM ALAN ROSARIO APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2019
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W GORE ST STE 600
ORLANDO FL
32806-1051
US

IV. Provider business mailing address

100 W GORE ST STE 600
ORLANDO FL
32806-1051
US

V. Phone/Fax

Practice location:
  • Phone: 321-842-6671
  • Fax: 321-843-6447
Mailing address:
  • Phone: 321-842-6671
  • Fax: 321-843-6447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN11014592
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2289024
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: