Provider Demographics
NPI:1902055965
Name:MORTENSEN, ERIK P (NP)
Entity type:Individual
Prefix:MR
First Name:ERIK
Middle Name:P
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8390 CHAMPIONS GATE BLVD
Mailing Address - Street 2:STE 215
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8310
Mailing Address - Country:US
Mailing Address - Phone:321-401-1364
Mailing Address - Fax:407-390-1765
Practice Address - Street 1:352 7TH AVE
Practice Address - Street 2:RM 1205
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5411
Practice Address - Country:US
Practice Address - Phone:212-627-7560
Practice Address - Fax:212-627-7563
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304475363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health