Provider Demographics
NPI:1972327245
Name:TRONCOSO CANELA, GREGORI RAFAEL
Entity type:Individual
Prefix:
First Name:GREGORI
Middle Name:RAFAEL
Last Name:TRONCOSO CANELA
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:Y25 CALLE VIOLETA
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00985-4251
Mailing Address - Country:US
Mailing Address - Phone:939-383-3113
Mailing Address - Fax:
Practice Address - Street 1:505 AVE HOSTOS
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3201
Practice Address - Country:US
Practice Address - Phone:787-488-0292
Practice Address - Fax:939-355-0129
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRPA1589363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty