Provider Demographics
NPI:1427719624
Name:DEMOSTHENE, REAL (FNP)
Entity type:Individual
Prefix:
First Name:REAL
Middle Name:
Last Name:DEMOSTHENE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 IBIZAN CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-3216
Mailing Address - Country:US
Mailing Address - Phone:321-444-9220
Mailing Address - Fax:
Practice Address - Street 1:5730 IBIZAN CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-3216
Practice Address - Country:US
Practice Address - Phone:321-444-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11017257363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care