Healthcare Provider Details

I. General information

NPI: 1780132001
Provider Name (Legal Business Name): BERNARDO TRUJILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12967 US HIGHWAY 301 S
RIVERVIEW FL
33578-7647
US

IV. Provider business mailing address

12967 US HIGHWAY 301 S
RIVERVIEW FL
33578-7647
US

V. Phone/Fax

Practice location:
  • Phone: 813-443-6369
  • Fax: 813-280-2584
Mailing address:
  • Phone: 813-443-6369
  • Fax: 813-280-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9287894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: