Healthcare Provider Details

I. General information

NPI: 1417911439
Provider Name (Legal Business Name): LEONARD JOHN GONZALES JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15790 PAUL VEGA MD DR
HAMMOND LA
70403-1434
US

IV. Provider business mailing address

PO BOX 2668
HAMMOND LA
70404-2668
US

V. Phone/Fax

Practice location:
  • Phone: 985-230-6685
  • Fax: 985-230-2173
Mailing address:
  • Phone: 985-230-6685
  • Fax: 985-230-2173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP02613
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: