Healthcare Provider Details

I. General information

NPI: 1386576460
Provider Name (Legal Business Name): JARETT GONGORA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 GLENCOVE LN
GRETNA LA
70056-4427
US

IV. Provider business mailing address

775 GLENCOVE LN
GRETNA LA
70056-4427
US

V. Phone/Fax

Practice location:
  • Phone: 504-812-0057
  • Fax:
Mailing address:
  • Phone: 504-812-0057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number210985
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: