Provider Demographics
NPI:1790185353
Name:GONGORA, DELIA T
Entity Type:Individual
Prefix:
First Name:DELIA
Middle Name:T
Last Name:GONGORA
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 1:1191 NW 134TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2220
Mailing Address - Country:US
Mailing Address - Phone:786-269-4661
Mailing Address - Fax:
Practice Address - Street 1:14283 SW 42ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6408
Practice Address - Country:US
Practice Address - Phone:305-226-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-01
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLS00894589363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily