Provider Demographics
NPI:1497326920
Name:BURGOS, SHANNON ROXSANNE (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROXSANNE
Last Name:BURGOS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12306 MOSS LAKE LOOP
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2328
Mailing Address - Country:US
Mailing Address - Phone:727-290-8145
Mailing Address - Fax:
Practice Address - Street 1:10970 CROSS CREEK BLVD FL 33647D
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-4055
Practice Address - Country:US
Practice Address - Phone:813-369-5969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11013994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily