Healthcare Provider Details

I. General information

NPI: 1316394869
Provider Name (Legal Business Name): JERRY GOMEZ ROSADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2016
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9655 BOYNTON BEACH BLVD
BOYNTON BEACH FL
33472-4421
US

IV. Provider business mailing address

W27 CALLE SAN JOAQUIN URB.MARIOLGA
CAGUAS PR
00725-6452
US

V. Phone/Fax

Practice location:
  • Phone: 561-737-7733
  • Fax:
Mailing address:
  • Phone: 787-641-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number105546
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9474204
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: