=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992566079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIGUEL TRISTA APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2024
-----------------------------------------------------
Last Update Date | 04/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12651 WHITEHALL DR
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-3626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-424-2030
-----------------------------------------------------
Fax | 239-343-4117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2147
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33902-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-424-2030
-----------------------------------------------------
Fax | 239-343-4117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 11031625
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11031625
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------