Healthcare Provider Details

I. General information

NPI: 1821914680
Provider Name (Legal Business Name): MIA GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HENRY CLAY AVE
NEW ORLEANS LA
70118-5720
US

IV. Provider business mailing address

2010 REPOSE ST
VIOLET LA
70092-3046
US

V. Phone/Fax

Practice location:
  • Phone: 504-899-9511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number354013
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: