Healthcare Provider Details

I. General information

NPI: 1245795996
Provider Name (Legal Business Name): ANTONIO CORDOVA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12900 CORTEZ BLVD STE 102
BROOKSVILLE FL
34613-6897
US

IV. Provider business mailing address

202 ERIC CT
TAMPA FL
33615
US

V. Phone/Fax

Practice location:
  • Phone: 352-596-7660
  • Fax: 352-596-5581
Mailing address:
  • Phone: 352-277-5305
  • Fax: 352-616-0926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11000965
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11000965
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: