Provider Demographics
NPI:1992566079
Name:TRISTA, MIGUEL (APRN)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:TRISTA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-2030
Mailing Address - Fax:239-343-4117
Practice Address - Street 1:12651 WHITEHALL DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3626
Practice Address - Country:US
Practice Address - Phone:239-424-2030
Practice Address - Fax:239-343-4117
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11031625363L00000X
FLAPRN11031625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121575700Medicaid