Healthcare Provider Details

I. General information

NPI: 1649836214
Provider Name (Legal Business Name): GILLIAN ROSENBERGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 TYRONE BLVD N
ST PETERSBURG FL
33710-7126
US

IV. Provider business mailing address

4874 COQUINA KEY DR SE APT B
ST PETERSBURG FL
33705-6318
US

V. Phone/Fax

Practice location:
  • Phone: 727-528-7827
  • Fax:
Mailing address:
  • Phone: 941-993-4225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112379
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9112379
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: