Basic Information
| Provider Information | |||||||||
| NPI: | 1720657588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JOSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9278 NW 13TH PL | ||||||||
| Address2: | |||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330716602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862860537 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3580 LAKE WORTH RD | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334614029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614255075 | ||||||||
| FaxNumber: | 5612757134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2021 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11013866 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 11013866 | 01 | FL | LICENSE | OTHER |