Provider Demographics
NPI:1790502540
Name:ROQUE, YAISER (APRN)
Entity type:Individual
Prefix:
First Name:YAISER
Middle Name:
Last Name:ROQUE
Suffix:
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 1:17901 SUMMERLIN RD STE C
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5765
Mailing Address - Country:US
Mailing Address - Phone:239-291-3602
Mailing Address - Fax:
Practice Address - Street 1:17901 SUMMERLIN RD STE C
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-5765
Practice Address - Country:US
Practice Address - Phone:239-291-3602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018860363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily