Provider Demographics
NPI:1568605699
Name:PEDRO GONZALEZ PA
Entity Type:Organization
Organization Name:PEDRO GONZALEZ PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:305-275-7029
Mailing Address - Street 1:1259 BLUEBIRD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-3117
Mailing Address - Country:US
Mailing Address - Phone:305-275-7029
Mailing Address - Fax:305-275-7066
Practice Address - Street 1:1259 BLUEBIRD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-3117
Practice Address - Country:US
Practice Address - Phone:305-275-7029
Practice Address - Fax:305-275-7066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100617363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5656ZMedicare Oscar/Certification