Provider Demographics
NPI:1083363444
Name:GOROBTSOV, EVGENY
Entity Type:Individual
Prefix:
First Name:EVGENY
Middle Name:
Last Name:GOROBTSOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5996 ORCHIS RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-6722
Mailing Address - Country:US
Mailing Address - Phone:269-548-6961
Mailing Address - Fax:
Practice Address - Street 1:2600 LAUREL RD E
Practice Address - Street 2:
Practice Address - City:NORTH VENICE
Practice Address - State:FL
Practice Address - Zip Code:34275-3226
Practice Address - Country:US
Practice Address - Phone:941-261-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11018597363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology