Healthcare Provider Details

I. General information

NPI: 1063981447
Provider Name (Legal Business Name): ERIK TYLER BORGSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4427 W LEILA AVE
TAMPA FL
33616-1007
US

IV. Provider business mailing address

4427 W LEILA AVE
TAMPA FL
33616-1007
US

V. Phone/Fax

Practice location:
  • Phone: 727-459-8188
  • Fax:
Mailing address:
  • Phone: 727-459-8188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9438147
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: