Healthcare Provider Details

I. General information

NPI: 1124673512
Provider Name (Legal Business Name): JUAN ENRIQUE GONZALEZ NAZARIO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2019
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVE
SYRACUSE NY
13210-1602
US

IV. Provider business mailing address

1 TAMPA GENERAL CIR
TAMPA FL
33606-3571
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7111
  • Fax:
Mailing address:
  • Phone: 813-844-4434
  • Fax: 865-867-6561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11003404
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number885579
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: