Provider Demographics
NPI:1548918378
Name:RODRIGUEZ GONZALEZ, ENITT ANDREINA
Entity type:Individual
Prefix:
First Name:ENITT
Middle Name:ANDREINA
Last Name:RODRIGUEZ GONZALEZ
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 1:12635 N ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-2124
Mailing Address - Country:US
Mailing Address - Phone:305-901-9475
Mailing Address - Fax:
Practice Address - Street 1:12635 N ROSEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-2124
Practice Address - Country:US
Practice Address - Phone:305-901-9475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1199363A00000X
PR1199-P.A.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant