Healthcare Provider Details

I. General information

NPI: 1477109700
Provider Name (Legal Business Name): JUAN CARLOS GONZALEZ M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER MSC09-5030
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER MSC09-5030
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5428
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: