Provider Demographics
NPI:1215767157
Name:SURIN, MARNEL GREGORY
Entity type:Individual
Prefix:MR
First Name:MARNEL
Middle Name:GREGORY
Last Name:SURIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 FOWLER GROVE BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5050
Mailing Address - Country:US
Mailing Address - Phone:407-889-1930
Mailing Address - Fax:
Practice Address - Street 1:2000 FOWLER GROVE BLVD FL 3
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-5050
Practice Address - Country:US
Practice Address - Phone:407-889-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9119114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant