Healthcare Provider Details

I. General information

NPI: 1245730027
Provider Name (Legal Business Name): VIRGILIO GONZAGA JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2018
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date: 08/08/2020
Reactivation Date: 07/22/2021

III. Provider practice location address

1401 PELHAM PKWY N
BRONX NY
10469-5809
US

IV. Provider business mailing address

174 BAIER AVE APT 106
SOMERSET NJ
08873-2043
US

V. Phone/Fax

Practice location:
  • Phone: 917-331-7177
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number725963
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: