Healthcare Provider Details

I. General information

NPI: 1174378061
Provider Name (Legal Business Name): EDGARDO MEJIAS CHACON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 04/23/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13926 HENSON CIR
TAMPA FL
33625-3121
US

IV. Provider business mailing address

13926 HENSON CIR
TAMPA FL
33625-3121
US

V. Phone/Fax

Practice location:
  • Phone: 813-240-8377
  • Fax:
Mailing address:
  • Phone: 813-240-8377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11032256
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: