Healthcare Provider Details

I. General information

NPI: 1700992559
Provider Name (Legal Business Name): MAGDALENA MARIE GONZALEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N 35TH AVE STE 600
HOLLYWOOD FL
33021
US

IV. Provider business mailing address

2900 CORPORATE WAY DOOR D
MIRAMAR FL
33025-3925
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-5961
  • Fax: 954-265-2933
Mailing address:
  • Phone: 954-276-5685
  • Fax: 954-985-7074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9103081
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: