Provider Demographics
NPI:1306031232
Name:SAN JUAN, RODOLFO GONZALES (RN)
Entity Type:Individual
Prefix:MR
First Name:RODOLFO
Middle Name:GONZALES
Last Name:SAN JUAN
Suffix:
Gender:M
Credentials:RN
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Mailing Address - Street 1:480 CENTRAL AVE
Mailing Address - Street 2:NAVAL HEALTH CLINIC HAWAII
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HI
Mailing Address - Zip Code:96860-4908
Mailing Address - Country:US
Mailing Address - Phone:808-473-1880
Mailing Address - Fax:808-473-4411
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:NAVAL HEALTH CLINIC HAWAII
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:808-473-1880
Practice Address - Fax:808-473-4411
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA00156971163W00000X
WA00006824247100000X
MN284362247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist