Healthcare Provider Details

I. General information

NPI: 1114021698
Provider Name (Legal Business Name): FIDEL GONZALEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST
MIAMI FL
33125-1624
US

IV. Provider business mailing address

4121 SW 141ST AVE
DAVIE FL
33330-5723
US

V. Phone/Fax

Practice location:
  • Phone: 305-324-4455
  • Fax: 305-575-3161
Mailing address:
  • Phone: 305-324-4455
  • Fax: 305-575-3161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2112
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: