Provider Demographics
NPI:1740808385
Name:GONZALEZ, JESUS IVAN (APRN)
Entity type:Individual
Prefix:MR
First Name:JESUS
Middle Name:IVAN
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:JESUS
Other - Middle Name:IVAN
Other - Last Name:GONZALEZ BATISTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22628 ROYAL RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-8781
Mailing Address - Country:US
Mailing Address - Phone:305-300-7590
Mailing Address - Fax:
Practice Address - Street 1:2700 HEALING WAY STE 310
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-5453
Practice Address - Country:US
Practice Address - Phone:813-779-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11007931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily