Healthcare Provider Details

I. General information

NPI: 1275994071
Provider Name (Legal Business Name): SUSAN IRENE BORGIASZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN IRENE BANASZAK FNP-BC

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 MANATEE AVE W STE 100
BRADENTON FL
34205-4954
US

IV. Provider business mailing address

5130 SUNFOREST DR STE 300
TAMPA FL
33634-6327
US

V. Phone/Fax

Practice location:
  • Phone: 941-847-7920
  • Fax: 941-757-2291
Mailing address:
  • Phone: 727-824-0780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173210
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9474864
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: