Basic Information
| Provider Information | |||||||||
| NPI: | 1194052811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REALISTA | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | BUSA | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 S ORLANDO AVE STE C | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078944693 | ||||||||
| FaxNumber: | 4072613869 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 N ORANGE AVE STE 537N | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078944693 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2009 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9223946 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.