Provider Demographics
NPI:1215405709
Name:GONZALEZ, ERNESTO (PTA)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8217 ABBOTT AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33141-5227
Mailing Address - Country:US
Mailing Address - Phone:305-326-3355
Mailing Address - Fax:
Practice Address - Street 1:8612 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33328-3719
Practice Address - Country:US
Practice Address - Phone:954-252-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28897225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty