Healthcare Provider Details

I. General information

NPI: 1740792795
Provider Name (Legal Business Name): MARIO ALBERTO GONZALEZ MSN/FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 N STATE ST STE 5
SAN JACINTO CA
92583-6574
US

IV. Provider business mailing address

27373 FAWN RIDGE CT
CORONA CA
92883-8413
US

V. Phone/Fax

Practice location:
  • Phone: 951-487-8506
  • Fax:
Mailing address:
  • Phone: 562-278-4727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95007892
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: