Provider Demographics
NPI:1750125688
Name:PROTASEWICZ, MICHAEL JAN JR (APRN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAN
Last Name:PROTASEWICZ
Suffix:JR
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14339 VIBURNUM LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7202
Mailing Address - Country:US
Mailing Address - Phone:407-666-5543
Mailing Address - Fax:
Practice Address - Street 1:12780 WATERFORD LAKES PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4500
Practice Address - Country:US
Practice Address - Phone:407-384-1053
Practice Address - Fax:407-277-8168
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026965363LF0000X
FLAPRN11026965363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily