Healthcare Provider Details

I. General information

NPI: 1073275756
Provider Name (Legal Business Name): AUTUMN MARIE GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2021
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST RD STE A
LOS ALAMOS NM
87544-2292
US

IV. Provider business mailing address

3917 WEST RD STE A
LOS ALAMOS NM
87544-2292
US

V. Phone/Fax

Practice location:
  • Phone: 505-661-8900
  • Fax:
Mailing address:
  • Phone: 505-661-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2023-0240
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: