MEDICARE: DR. JOSE LUIS GONZALEZ-ROMAN APRN,FNP-C,PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APRN11012338	FL
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN11012338	FL
3	363LF0000X	Family Nurse Practitioner	GAA-NP-000179	GA

General Provider Information

NPI Number	:	1063187128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSE LUIS GONZALEZ-ROMAN APRN,FNP-C,PMHNP-BC

Provider Business Mailing Address
First Line	:	14888 SUMMER BRANCH DR
Second Line	:
City	:	LITHIA
State	:	FL
Zip	:	33547-5130
Country	:	US
Telephone Number	:	813-502-9354
Fax Number	:

Provider Business Practice Location Address
First Line	:	14888 SUMMER BRANCH DR
Second Line	:
City	:	LITHIA
State	:	FL
Zip	:	33547-5130
Country	:	US
Telephone Number	:	813-502-9354
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2021
Last Update Date	:	01/21/2025

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