Healthcare Provider Details

I. General information

NPI: 1104688563
Provider Name (Legal Business Name): BRYAN GONZALEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4765 SW 148TH AVE STE 404
DAVIE FL
33330-2128
US

IV. Provider business mailing address

4765 SW 148TH AVE STE 404
DAVIE FL
33330-2128
US

V. Phone/Fax

Practice location:
  • Phone: 954-374-7545
  • Fax: 954-374-7543
Mailing address:
  • Phone: 954-374-7545
  • Fax: 954-374-7543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9118524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: