Provider Demographics
NPI:1194493874
Name:GONZALEZ, MYRIAM YAHAIRA
Entity type:Individual
Prefix:
First Name:MYRIAM
Middle Name:YAHAIRA
Last Name: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:PO BOX 2074
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-2074
Mailing Address - Country:US
Mailing Address - Phone:787-433-3911
Mailing Address - Fax:
Practice Address - Street 1:FAIRWAY COURTS
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-433-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22486208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty