Provider Demographics
NPI:1255001418
Name:TANK, JUSTIN CHRISTOPHER
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CHRISTOPHER
Last Name:TANK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3372 SPRING PARK WAY
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-8108
Mailing Address - Country:US
Mailing Address - Phone:352-232-0932
Mailing Address - Fax:
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-821-8038
Practice Address - Fax:813-974-0483
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014573363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114477300Medicaid
FL0YS4MOtherBCBS