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General NPI Number Information
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NPI Number | 1710515564
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Entity Type | Organization
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Legal Business Name | PCP 1ST
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Dates
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Enumeration Date | 03/28/2020
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Last Update Date | 03/28/2020
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Provider Practice Location Address
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Address Line | 17188 NEWPORT CLUB DR
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City | BOCA RATON
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State | FL
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Zip | 33496-3009
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Country | US
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Telephone | 954-803-3564
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Fax |
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Provider Business Mailing Address
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Address Line | 2901 CLINT MOORE RD # 119
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City | BOCA RATON
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State | FL
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Zip | 33496-2041
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Country | US
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Telephone | 954-803-3564
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | YEENY GONZALEZ
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Credential |
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Telephone | 954-803-3564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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