Provider Demographics
NPI:1821161209
Name:GOROSPE, BELTECEZAR CRUZ (PA)
Entity Type:Individual
Prefix:
First Name:BELTECEZAR
Middle Name:CRUZ
Last Name:GOROSPE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 S ASPEN ST STOP 89
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80011-9562
Mailing Address - Country:US
Mailing Address - Phone:207-847-7473
Mailing Address - Fax:
Practice Address - Street 1:275 S ASPEN ST STOP 89
Practice Address - Street 2:
Practice Address - City:BUCKLEY AFB
Practice Address - State:CO
Practice Address - Zip Code:80011-9562
Practice Address - Country:US
Practice Address - Phone:720-847-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1049956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1049956OtherNCCPA CERTIFICATE NUMBER