Provider Demographics
NPI:1992198592
Name:JAVIER, ROBERTO GONZAGA (RN)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:GONZAGA
Last Name:JAVIER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450B 188TH ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3742
Mailing Address - Country:US
Mailing Address - Phone:718-969-0658
Mailing Address - Fax:
Practice Address - Street 1:6450B 188TH ST APT 1C
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-3742
Practice Address - Country:US
Practice Address - Phone:718-969-0658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY662816163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse