Provider Demographics
NPI:1215322037
Name:MINOZA, EDILBERTO
Entity type:Individual
Prefix:
First Name:EDILBERTO
Middle Name:
Last Name:MINOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4827 WANDERING PINES TRL S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1572
Mailing Address - Country:US
Mailing Address - Phone:904-294-8068
Mailing Address - Fax:
Practice Address - Street 1:423 S SAN JOAQUIN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-3537
Practice Address - Country:US
Practice Address - Phone:209-565-9929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAG0215089363LP2300X
CA95009794363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care