Healthcare Provider Details

I. General information

NPI: 1003539354
Provider Name (Legal Business Name): MARGENIS PEREZ GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 CALLE DE DIEGO
SAN JUAN PR
00923-3002
US

IV. Provider business mailing address

371 CALLE DE DIEGO
SAN JUAN PR
00923-3002
US

V. Phone/Fax

Practice location:
  • Phone: 787-767-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1257
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: