Provider Demographics
NPI:1649836214
Name:ROSENBERGER, GILLIAN
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:ROSENBERGER
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 1:4874 COQUINA KEY DR SE APT B
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-6318
Mailing Address - Country:US
Mailing Address - Phone:941-993-4225
Mailing Address - Fax:
Practice Address - Street 1:640 TYRONE BLVD N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-7126
Practice Address - Country:US
Practice Address - Phone:727-528-7827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-19
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112379363A00000X, 363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program