Provider Demographics
NPI:1639828106
Name:NORDSTROM, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:NORDSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11404 PALM PASTURE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-6317
Mailing Address - Country:US
Mailing Address - Phone:813-495-1055
Mailing Address - Fax:
Practice Address - Street 1:10987 SHELDON RD STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4702
Practice Address - Country:US
Practice Address - Phone:813-467-4800
Practice Address - Fax:813-467-4252
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
FLPA9115968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical