Healthcare Provider Details

I. General information

NPI: 1649237512
Provider Name (Legal Business Name): BOBBY EUGNE TIPTON JR. ANP-BC, CPNP-PC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N CLYDE MORRIS BLVD SUITE 550
DAYTONA BEACH FL
32114-2766
US

IV. Provider business mailing address

311 N CLYDE MORRIS BLVD STE 550
DAYTONA BEACH FL
32114-2766
US

V. Phone/Fax

Practice location:
  • Phone: 386-425-8582
  • Fax: 386-252-1776
Mailing address:
  • Phone: 386-425-8582
  • Fax: 386-252-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberA95318
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5005055
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5005055
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP3018142
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: