Healthcare Provider Details

I. General information

NPI: 1427574235
Provider Name (Legal Business Name): MARISSA GONZALEZ IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS MARISSA GONZALEZ

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 5071
APO AP
96328-5071
US

IV. Provider business mailing address

2105 W BOONE AVE
SPOKANE WA
99201-2901
US

V. Phone/Fax

Practice location:
  • Phone: 210-475-2413
  • Fax:
Mailing address:
  • Phone: 210-995-5051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: