Provider Demographics
NPI:1013671569
Name:SUSTACHE MERCADO, GABRIEL JOSUE (APRN)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:JOSUE
Last Name:SUSTACHE MERCADO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:321-841-7700
Mailing Address - Fax:321-841-7799
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:321-841-7700
Practice Address - Fax:321-841-7799
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015750363L00000X
FLAPRN11015750363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner