Provider Demographics
NPI:1902227655
Name:LACUROM, FERDINAND GONZALES (MSN-FNP, BSP, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:FERDINAND
Middle Name:GONZALES
Last Name:LACUROM
Suffix:
Gender:M
Credentials:MSN-FNP, BSP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:1313 BLUE SAGE WAY
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1616
Mailing Address - Country:US
Mailing Address - Phone:619-947-6418
Mailing Address - Fax:
Practice Address - Street 1:1313 BLUE SAGE WAY
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-1616
Practice Address - Country:US
Practice Address - Phone:619-947-6418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-25
Last Update Date:2013-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000164363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily