Healthcare Provider Details

I. General information

NPI: 1609675768
Provider Name (Legal Business Name): EDWIN ALBERTO BRACHO BOSCAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2025
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 N DALE MABRY HWY
TAMPA FL
33614-2665
US

IV. Provider business mailing address

7171 N DALE MABRY HWY
TAMPA FL
33614-2665
US

V. Phone/Fax

Practice location:
  • Phone: 813-558-8070
  • Fax:
Mailing address:
  • Phone: 813-558-8070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number16-316
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: