MEDICARE: EDMUND BONGOLAN ARNP

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	363L00000X	Nurse Practitioner	ARNP9310211	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073037297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDMUND BONGOLAN ARNP

Provider Business Mailing Address
First Line	:	5204 HAMPTON BEACH PL
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-2498
Country	:	US
Telephone Number	:	813-732-1749
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 N WEST SHORE BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-1122
Country	:	US
Telephone Number	:	813-533-7080
Fax Number	:

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

Provider Enumeration Date	:	07/30/2017
Last Update Date	:	08/20/2020

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