Provider Demographics
NPI:1548756893
Name:BORDELON, CHRISTOPHER JACOB (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JACOB
Last Name:BORDELON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10414 NIGHTENGALE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-4125
Mailing Address - Country:US
Mailing Address - Phone:813-789-0565
Mailing Address - Fax:
Practice Address - Street 1:2550 W DR MARTIN LUTHER KING JR BLVD STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6302
Practice Address - Country:US
Practice Address - Phone:813-876-6483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111443363AM0700X
MO2018024459363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101257900Medicaid