Provider Demographics
NPI:1649647264
Name:GONGORA MAYO, ALBERTO JORGE (APRN)
Entity type:Individual
Prefix:
First Name:ALBERTO
Middle Name:JORGE
Last Name:GONGORA MAYO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7050 W FLAGLER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2749
Mailing Address - Country:US
Mailing Address - Phone:786-515-3685
Mailing Address - Fax:
Practice Address - Street 1:7050 W FLAGLER ST APT 3
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2749
Practice Address - Country:US
Practice Address - Phone:786-515-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008846363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty