Provider Demographics
NPI:1396354627
Name:FUNDORA GONZALEZ, IBSEN (APRN)
Entity type:Individual
Prefix:MR
First Name:IBSEN
Middle Name:
Last Name:FUNDORA GONZALEZ
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 1:2610 SW 114TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2106
Mailing Address - Country:US
Mailing Address - Phone:561-255-9330
Mailing Address - Fax:
Practice Address - Street 1:4850 W OAKLAND PARK BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7268
Practice Address - Country:US
Practice Address - Phone:954-735-3535
Practice Address - Fax:954-484-7000
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008252363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty