Provider Demographics
NPI:1689064818
Name:SAN JOSE, GERTRUDE PATRICIA
Entity Type:Individual
Prefix:
First Name:GERTRUDE
Middle Name:PATRICIA
Last Name:SAN JOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-5983
Mailing Address - Country:US
Mailing Address - Phone:732-701-3184
Mailing Address - Fax:732-746-4421
Practice Address - Street 1:570 ROUTE 70
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-4014
Practice Address - Country:US
Practice Address - Phone:732-242-7411
Practice Address - Fax:732-746-4421
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ580132146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic