Healthcare Provider Details

I. General information

NPI: 1285003608
Provider Name (Legal Business Name): ROBERT GONZALEZ JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49725 COUNTY 83
STAPLES MN
56479-5280
US

IV. Provider business mailing address

12902 KNOLLWOOD DR
BAXTER MN
56425-8373
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1515
  • Fax:
Mailing address:
  • Phone: 915-422-6375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number195330-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: