Healthcare Provider Details

I. General information

NPI: 1992592778
Provider Name (Legal Business Name): DANIEL GONZALES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

IV. Provider business mailing address

8401 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7604
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-0329
  • Fax:
Mailing address:
  • Phone: 505-630-5574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: