Healthcare Provider Details

I. General information

NPI: 1992784649
Provider Name (Legal Business Name): JOSE B GARDENS PA, CHE.ABQAURP.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 HARRISON PKWY #200
SUNRISE FL
33323-2853
US

IV. Provider business mailing address

5201 WATERFORD DISTRICT DR
MIAMI FL
33126-2064
US

V. Phone/Fax

Practice location:
  • Phone: 954-838-2371
  • Fax:
Mailing address:
  • Phone: 786-223-7523
  • Fax: 786-551-5886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9100180
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: