Basic Information
| Provider Information | |||||||||
| NPI: | 1245795996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDOVA | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | JOSE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 MARINER BLVD | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346095603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522775305 | ||||||||
| FaxNumber: | 3526160926 | ||||||||
| Practice Location | |||||||||
| Address1: | 12900 CORTEZ BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346136897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525967660 | ||||||||
| FaxNumber: | 3525965581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2019 | ||||||||
| LastUpdateDate: | 10/16/2019 | ||||||||
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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 | 363LA2200X | APRN11000965 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 11000965 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 11000965 | 05 | FL | MEDICAID | APRN11000965 | 01 | FL | FL MEDICAL LICENSE | OTHER |