Provider Demographics
NPI:1205710118
Name:GAETAN, ANGEL MANUEL (OWNER)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:MANUEL
Last Name:GAETAN
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10777 W SAMPLE RD APT 208
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-3768
Mailing Address - Country:US
Mailing Address - Phone:954-793-0905
Mailing Address - Fax:
Practice Address - Street 1:10777 W SAMPLE RD APT 208
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-3768
Practice Address - Country:US
Practice Address - Phone:954-793-0905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLG225637380000172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver