Provider Demographics
NPI:1245795996
Name:CORDOVA, ANTONIO JOSE (APRN)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:JOSE
Last Name:CORDOVA
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 1:1202 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-5603
Mailing Address - Country:US
Mailing Address - Phone:352-277-5305
Mailing Address - Fax:352-616-0926
Practice Address - Street 1:12900 CORTEZ BLVD STE 102
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6897
Practice Address - Country:US
Practice Address - Phone:352-596-7660
Practice Address - Fax:352-596-5581
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000965363LA2200X
FL11000965363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11000965Medicaid
FLAPRN11000965OtherFL MEDICAL LICENSE