Provider Demographics
NPI:1649237512
Name:TIPTON, BOBBY EUGNE JR (ANP-BC, CPNP-PC)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:EUGNE
Last Name:TIPTON
Suffix:JR
Gender:M
Credentials:ANP-BC, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:311 N CLYDE MORRIS BLVD STE 550
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2766
Mailing Address - Country:US
Mailing Address - Phone:386-425-8582
Mailing Address - Fax:386-252-1776
Practice Address - Street 1:311 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 550
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2766
Practice Address - Country:US
Practice Address - Phone:386-425-8582
Practice Address - Fax:386-252-1776
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCA95318363LA2100X
NC5005055363LA2200X, 363LP0200X
FLARNP3018142363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0829Medicaid
SCNP0829Medicaid
AA05441955Medicare ID - Type Unspecified