Provider Demographics
NPI:1104688563
Name:GONZALEZ, BRYAN (PA-C)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
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 1:4765 SW 148TH AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-2128
Mailing Address - Country:US
Mailing Address - Phone:954-374-7545
Mailing Address - Fax:954-374-7543
Practice Address - Street 1:4765 SW 148TH AVE STE 404
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-2128
Practice Address - Country:US
Practice Address - Phone:954-374-7545
Practice Address - Fax:954-374-7543
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9118524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant