Provider Demographics
NPI:1962458257
Name:SOUZA, MANUEL JOHN (MS, ANP-BC)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:JOHN
Last Name:SOUZA
Suffix:
Gender:
Credentials:MS, ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12670 CREEKSIDE LN STE 202
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3370
Mailing Address - Country:US
Mailing Address - Phone:239-482-2663
Mailing Address - Fax:239-482-7585
Practice Address - Street 1:8350 RIVERWALK PARK BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8759
Practice Address - Country:US
Practice Address - Phone:239-482-2663
Practice Address - Fax:239-482-7585
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA193850363LA2200X
FLAPRN9168451363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY9368OtherBLUE SHIELD
FL303290600Medicaid
500018529OtherRAIL ROAD MEDICARE
FL303290600Medicaid