Provider Demographics
NPI:1841538469
Name:GOZUM, JAY LOPEZ (NP)
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:LOPEZ
Last Name:GOZUM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 MARBLE CANYON WAY
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1646
Mailing Address - Country:US
Mailing Address - Phone:619-302-3893
Mailing Address - Fax:
Practice Address - Street 1:3202 DUKE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5401
Practice Address - Country:US
Practice Address - Phone:619-302-3893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF0411057363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily