Healthcare Provider Details

I. General information

NPI: 1912824756
Provider Name (Legal Business Name): GIANKARLOS RODRIGUEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 DELSEA DR
DEPTFORD NJ
08096-4101
US

IV. Provider business mailing address

1410 DELSEA DR
DEPTFORD NJ
08096-4101
US

V. Phone/Fax

Practice location:
  • Phone: 856-579-8897
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067730
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP01045500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: