Provider Demographics
NPI:1629439682
Name:BURGOS, GUSTAVO
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:BURGOS
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:HC 1 BOX 4571
Mailing Address - Street 2:
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767-9648
Mailing Address - Country:US
Mailing Address - Phone:787-449-9446
Mailing Address - Fax:
Practice Address - Street 1:CARR 901 KIL 4
Practice Address - Street 2:BARRIO CAMINO NUEVO HM8
Practice Address - City:YABUCOA
Practice Address - State:PR
Practice Address - Zip Code:00767
Practice Address - Country:US
Practice Address - Phone:787-641-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR78149G163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse