Provider Demographics
NPI:1780629527
Name:GARCIA, MARINO GUSTAVO (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARINO
Middle Name:GUSTAVO
Last Name:GARCIA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 EAGLE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813
Mailing Address - Country:US
Mailing Address - Phone:863-607-4128
Mailing Address - Fax:
Practice Address - Street 1:300 PINELLAS ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756
Practice Address - Country:US
Practice Address - Phone:727-462-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX512453367500000X
FLARNP9238304367500000X
TX032066367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307717900Medicaid
G4005Medicare ID - Type Unspecified