Healthcare Provider Details

I. General information

NPI: 1497531057
Provider Name (Legal Business Name): JORGE RAFAEL GONZALEZ TRASOBARES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4578 W 12TH AVE
HIALEAH FL
33012-3325
US

IV. Provider business mailing address

12126 SW 249TH ST
HOMESTEAD FL
33032-5963
US

V. Phone/Fax

Practice location:
  • Phone: 305-828-1989
  • Fax: 786-791-1253
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11028394
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: