Provider Demographics
NPI:1881418275
Name:GONZALEZ, NICK ANDREW (PA-C)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:ANDREW
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PARK RD
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-1323
Mailing Address - Country:US
Mailing Address - Phone:787-356-2829
Mailing Address - Fax:
Practice Address - Street 1:14254 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-4414
Practice Address - Country:US
Practice Address - Phone:813-653-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9119542363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical