Provider Demographics
NPI:1659564524
Name:NOVA-FUSON, GLORIA C (CRNA)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:C
Last Name:NOVA-FUSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NOKOMIS AVE S
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3209
Mailing Address - Country:US
Mailing Address - Phone:941-485-0295
Mailing Address - Fax:941-484-0084
Practice Address - Street 1:600 NOKOMIS AVE S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3209
Practice Address - Country:US
Practice Address - Phone:941-485-0295
Practice Address - Fax:941-484-0084
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3188672367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308606200Medicaid
FLP00451266OtherMEDICARE RR
FLG4353OtherBCBSFL
FLP00451266OtherMEDICARE RR