Healthcare Provider Details

I. General information

NPI: 1689697278
Provider Name (Legal Business Name): JESUS GONZALEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14906 PARAMOUNT BLVD
PARAMOUNT CA
90723-3409
US

IV. Provider business mailing address

14906 PARAMOUNT BLVD
PARAMOUNT CA
90723-3409
US

V. Phone/Fax

Practice location:
  • Phone: 562-630-1991
  • Fax: 562-630-0145
Mailing address:
  • Phone: 562-630-1991
  • Fax: 562-630-0145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15959
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: