Provider Demographics
NPI:1316394869
Name:GOMEZ ROSADO, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:GOMEZ ROSADO
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:W27 CALLE SAN JOAQUIN
Mailing Address - Street 2:URB.MARIOLGA
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-6452
Mailing Address - Country:US
Mailing Address - Phone:787-641-7582
Mailing Address - Fax:
Practice Address - Street 1:9655 BOYNTON BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33472-4421
Practice Address - Country:US
Practice Address - Phone:561-737-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-14
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR105546367500000X
FLAPRN9474204367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered