MEDICARE: ERIK TYLER BORGSTROM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0200X	Critical Care Medicine Registered Nurse	RN9438147	FL

General Provider Information

NPI Number	:	1063981447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIK TYLER BORGSTROM

Provider Business Mailing Address
First Line	:	4427 W LEILA AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33616-1007
Country	:	US
Telephone Number	:	727-459-8188
Fax Number	:

Provider Business Practice Location Address
First Line	:	4427 W LEILA AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33616-1007
Country	:	US
Telephone Number	:	727-459-8188
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2018
Last Update Date	:	11/15/2018

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