MEDICARE: CHRISTOPHER JACOB BORDELON PA-C

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	363AM0700X	Medical Physician Assistant	PA9111443	FL
2	363AM0700X	Medical Physician Assistant	2018024459	MO

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	:	1548756893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER JACOB BORDELON PA-C

Provider Business Mailing Address
First Line	:	10414 NIGHTENGALE DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-4125
Country	:	US
Telephone Number	:	813-789-0565
Fax Number	:

Provider Business Practice Location Address
First Line	:	2550 W DR MARTIN LUTHER KING JR BLVD STE B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6302
Country	:	US
Telephone Number	:	813-876-6483
Fax Number	:

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

Provider Enumeration Date	:	07/10/2018
Last Update Date	:	09/15/2021

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