Provider Demographics
NPI:1104966019
Name:SHULSTAD, RAYMOND MAURICE (ARNP)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:MAURICE
Last Name:SHULSTAD
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:STE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:14521 UNIVERSITY POINT PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-5424
Practice Address - Country:US
Practice Address - Phone:813-977-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3352202363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00126263OtherRAILROAD MEDICARE
FLP00126263OtherRAILROAD MEDICARE
FLU2294Medicare PIN