Provider Demographics
NPI:1417444019
Name:NASRALLA, NASSER (ARNP)
Entity Type:Individual
Prefix:
First Name:NASSER
Middle Name:
Last Name:NASRALLA
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 1:1925 PERIDOT CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-3716
Mailing Address - Country:US
Mailing Address - Phone:321-297-0740
Mailing Address - Fax:
Practice Address - Street 1:2450 N ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-2316
Practice Address - Country:US
Practice Address - Phone:321-297-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9352697163W00000X
FLARNP9352697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1417444019Medicaid