Provider Demographics
NPI:1841707502
Name:STANGA, GERALD KEITH JR
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:KEITH
Last Name:STANGA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 SUMMER BAY CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3938
Mailing Address - Country:US
Mailing Address - Phone:321-759-6054
Mailing Address - Fax:
Practice Address - Street 1:8110 SUMMER BAY CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-3938
Practice Address - Country:US
Practice Address - Phone:321-759-6054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110980363A00000X
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty