Healthcare Provider Details

I. General information

NPI: 1043847569
Provider Name (Legal Business Name): ALYSSA VICTORIA GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5246 BRITTANY DR
BATON ROUGE LA
70808-9136
US

IV. Provider business mailing address

5246 BRITTANY DR
BATON ROUGE LA
70808-9136
US

V. Phone/Fax

Practice location:
  • Phone: 225-757-4142
  • Fax:
Mailing address:
  • Phone: 225-757-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberU5970
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: