Healthcare Provider Details

I. General information

NPI: 1821993007
Provider Name (Legal Business Name): ANDREW GONZALES VIRGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 S 4TH ST APT 8
LEWISBURG PA
17837-1866
US

IV. Provider business mailing address

39 S 4TH ST APT 8
LEWISBURG PA
17837-1866
US

V. Phone/Fax

Practice location:
  • Phone: 570-989-1132
  • Fax:
Mailing address:
  • Phone: 570-989-1132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP037418
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: