Provider Demographics
NPI:1144832049
Name:TSHIABA, RUSSELL MWENGELEKAYI (APRN)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:MWENGELEKAYI
Last Name:TSHIABA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:MR
Other - First Name:TSHIABA
Other - Middle Name:MWENGELEKAYI
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN, RN
Mailing Address - Street 1:601 E ROLLINS ST STE 400
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1248
Mailing Address - Country:US
Mailing Address - Phone:321-207-0174
Mailing Address - Fax:
Practice Address - Street 1:601 E ROLLINS ST STE 400
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:321-207-0174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008517363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care