MEDICARE: GABRIEL DIB TAISSOUN FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	11027767	FL

General Provider Information

NPI Number	:	1871018630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIEL DIB TAISSOUN FNP-C

Provider Business Mailing Address
First Line	:	17523 CANTARINA CV
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34211-1126
Country	:	US
Telephone Number	:	321-900-9818
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 UNIVERSITY PKWY STE 205
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34243-2973
Country	:	US
Telephone Number	:	941-351-1200
Fax Number	:	941-351-1201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2017
Last Update Date	:	07/28/2023

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