Basic Information
| Provider Information | |||||||||
| NPI: | 1558918979 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | MIGUEL | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 UNIVERSITY PLZ STE 205 | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076016208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018333000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 718 TEANECK RD | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018333000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2019 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 26NJ00962200 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LG0600X | 26NJ00962200 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 26NJ00962200 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 0702714 | 05 | NJ | MEDICAID | 1790396281 | 01 | NJ | TITAN HEALTH GROUP NPI# | OTHER |