Provider Demographics
NPI:1255607750
Name:GONZALEZ, KAILEN (PA)
Entity type:Individual
Prefix:
First Name:KAILEN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:4571 COLONIAL BLVD STE 110
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1156
Practice Address - Country:US
Practice Address - Phone:786-218-3593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113094363A00000X
FL9113094363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC956511OtherWELLCARE
SC9673961OtherAETNA
FL111378700Medicaid
SC1434PAMedicaid
SC80025208OtherSELECT HEALTH
SC19BS6OtherBCBS
FL3H9GMOtherBCBS
SCP01074499OtherRAILROAD MEDICARE