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General NPI Number Information
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NPI Number | 1639294002
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Entity Type | Individual
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Provider Name | LORI GONZALO RPA-C
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Gender | Female
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 04/29/2009
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Provider Practice Location Address
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Address Line | 2071 CLOVE RD GRASMERE MEDICAL PAVILLION
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City | STATEN ISLAND
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State | NY
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Zip | 10304-1671
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Country | US
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Telephone | 718-442-5550
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Fax | 718-556-3025
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Provider Business Mailing Address
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Address Line | 20 EMILY CT
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City | STATEN ISLAND
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State | NY
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Zip | 10307-2087
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Country | US
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Telephone | 718-966-1784
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Fax | 718-966-1969
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 009282
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License Number State | NY
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