Healthcare Provider Details

I. General information

NPI: 1811740657
Provider Name (Legal Business Name): SHAWN STATUTO APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 03/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 MARINER BLVD FL 34609
SPRING HILL FL
34609-5680
US

IV. Provider business mailing address

11195 MARSH WREN AVE
WEEKI WACHEE FL
34614-3034
US

V. Phone/Fax

Practice location:
  • Phone: 352-515-6000
  • Fax:
Mailing address:
  • Phone: 352-573-1715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11032264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: