Healthcare Provider Details

I. General information

NPI: 1962644690
Provider Name (Legal Business Name): SARA H GONZALEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2009
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 RIGGINS RD
TALLAHASSEE FL
32308-5317
US

IV. Provider business mailing address

PO BOX 13859
TALLAHASSEE FL
32317-3859
US

V. Phone/Fax

Practice location:
  • Phone: 850-877-4134
  • Fax: 850-402-9130
Mailing address:
  • Phone: 850-877-4134
  • Fax: 850-402-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9100999
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: