Basic Information
| Provider Information | |||||||||
| NPI: | 1013671569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUSTACHE MERCADO | ||||||||
| FirstName: | GABRIEL | ||||||||
| MiddleName: | JOSUE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218417700 | ||||||||
| FaxNumber: | 3218417799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218417700 | ||||||||
| FaxNumber: | 3218417799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2021 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 11015750 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | APRN11015750 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.