Provider Demographics
NPI:1376197541
Name:DISLA, GREGORY RAFAEL (FNP-C)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:RAFAEL
Last Name:DISLA
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5905 US HIGHWAY 301 S
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3800
Mailing Address - Country:US
Mailing Address - Phone:813-740-8463
Mailing Address - Fax:
Practice Address - Street 1:216 S SEMINOLE AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4738
Practice Address - Country:US
Practice Address - Phone:352-560-0333
Practice Address - Fax:813-931-1427
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAPRN11003473363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily