=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447761804
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODALYN GONZALEZ NZEWUNWAH PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2017
-----------------------------------------------------
Last Update Date | 07/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 WAUGHTOWN ST
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27127-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 133-679-2151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2494 MOSS GROVE XING
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-6422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-693-0114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 001007624
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------