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General NPI Number Information
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NPI Number | 1902170327
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Entity Type | Individual
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Provider Name | ERICHSEN R BONOSTRO PAC
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Gender | Male
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Dates
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Enumeration Date | 03/02/2012
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Last Update Date | 07/07/2017
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Provider Practice Location Address
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Address Line | 1324 LAKELAND HILLS BLVD
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City | LAKELAND
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State | FL
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Zip | 33805-4543
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Country | US
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Telephone | 863-687-1321
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Fax | 863-284-1730
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Provider Business Mailing Address
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Address Line | 1324 LAKELAND HILLS BLVD ATTN: MANAGED CARE DEPT.
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City | LAKELAND
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State | FL
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Zip | 33805
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9106442
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA9106442
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License Number State | FL
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