MEDICARE: VERALYN PENA GONZALEZ PT

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	225100000X	Physical Therapist	40QA00446700	NJ

General Provider Information

NPI Number	:	1508265778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VERALYN PENA GONZALEZ PT

Provider Business Mailing Address
First Line	:	2757 KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-5507
Country	:	US
Telephone Number	:	201-333-8004
Fax Number	:	201-333-8425

Provider Business Practice Location Address
First Line	:	2757 KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-5507
Country	:	US
Telephone Number	:	201-333-8004
Fax Number	:	201-333-8425

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

Provider Enumeration Date	:	08/13/2014
Last Update Date	:	08/13/2014

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