Healthcare Provider Details

I. General information

NPI: 1356005680
Provider Name (Legal Business Name): LORETTA GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10151 MONTGOMERY BLVD NE BLDG 1
ALBUQUERQUE NM
87111-3670
US

IV. Provider business mailing address

10151 MONTGOMERY BLVD NE BLDG 1
ALBUQUERQUE NM
87111-3670
US

V. Phone/Fax

Practice location:
  • Phone: 505-855-5503
  • Fax: 505-855-5533
Mailing address:
  • Phone: 505-855-5503
  • Fax: 505-855-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2023-0232
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: