Healthcare Provider Details

I. General information

NPI: 1275392805
Provider Name (Legal Business Name): YGONGORANP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 NW 36TH ST STE 213
VIRGINIA GARDENS FL
33166-6973
US

IV. Provider business mailing address

6405 NW 36TH ST STE 213
VIRGINIA GARDENS FL
33166-6973
US

V. Phone/Fax

Practice location:
  • Phone: 786-562-7479
  • Fax: 305-564-7610
Mailing address:
  • Phone: 786-562-7479
  • Fax: 305-564-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: YOVANY GONGORA
Title or Position: MANAGER
Credential: APRN
Phone: 786-660-1844