Healthcare Provider Details

I. General information

NPI: 1326072950
Provider Name (Legal Business Name): LIONEL MADRID GONZALES JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR SUITE 503
ORANGE CA
92868-3854
US

IV. Provider business mailing address

1310 W. STEWART DRIVE SUITE 503
ORANGE CA
92868-3856
US

V. Phone/Fax

Practice location:
  • Phone: 714-997-2224
  • Fax: 714-997-1187
Mailing address:
  • Phone: 714-997-2224
  • Fax: 714-997-1187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10115
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: