Healthcare Provider Details

I. General information

NPI: 1104028497
Provider Name (Legal Business Name): RICHARD GONZALEZ CST/CSFA, RNFA, CNOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E FLETCHER AVE
TAMPA FL
33613-4613
US

IV. Provider business mailing address

3412 WHITE TOWER WAY
HENRICO VA
23231-7294
US

V. Phone/Fax

Practice location:
  • Phone: 813-817-9969
  • Fax:
Mailing address:
  • Phone: 813-817-9969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number103780
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: