Basic Information
| Provider Information | |||||||||
| NPI: | 1174853923 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVOSTO | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | A.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135284975 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139772020 | ||||||||
| FaxNumber: | 8133555010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2009 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP9190830 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | P01191553 | 01 | FL | R&R MEDICARE | OTHER |