Provider Demographics
NPI:1235638602
Name:METELUS, GASTON (ARNP)
Entity Type:Individual
Prefix:
First Name:GASTON
Middle Name:
Last Name:METELUS
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 1:1893 KINGSLEY AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4421
Mailing Address - Country:US
Mailing Address - Phone:904-444-5046
Mailing Address - Fax:
Practice Address - Street 1:1893 KINGSLEY AVE STE C
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4421
Practice Address - Country:US
Practice Address - Phone:904-444-5046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9361373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily