Provider Demographics
NPI:1073037297
Name:BONGOLAN, EDMUND (ARNP)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:
Last Name:BONGOLAN
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5204 HAMPTON BEACH PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2498
Mailing Address - Country:US
Mailing Address - Phone:813-732-1749
Mailing Address - Fax:
Practice Address - Street 1:701 N WEST SHORE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1122
Practice Address - Country:US
Practice Address - Phone:813-533-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-30
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9310211363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner