Provider Demographics
NPI:1447585583
Name:VICTORIANO, GERARD M JR (PA)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:M
Last Name:VICTORIANO
Suffix:JR
Gender:M
Credentials:PA
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Mailing Address - Street 1:14050 NW 14TH ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2865
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:524 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5725
Practice Address - Country:US
Practice Address - Phone:337-491-7709
Practice Address - Fax:337-491-7157
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAPA.200317363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant