Provider Demographics
NPI:1306614920
Name:PORTAL LEMOCK, GONZALO (APRN)
Entity type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:PORTAL LEMOCK
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 1:18300 NW 62ND AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33015-8207
Mailing Address - Country:US
Mailing Address - Phone:786-677-9922
Mailing Address - Fax:844-895-3066
Practice Address - Street 1:18300 NW 62ND AVE STE 210
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33015-8207
Practice Address - Country:US
Practice Address - Phone:786-677-9922
Practice Address - Fax:844-895-3066
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11030115363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily