Healthcare Provider Details

I. General information

NPI: 1093576597
Provider Name (Legal Business Name): STEVEN GONZALEZ CPSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 MDWLRK LN SE
RIO RANCHO NM
87124-1021
US

IV. Provider business mailing address

PO BOX 15301
RIO RANCHO NM
87174-0301
US

V. Phone/Fax

Practice location:
  • Phone: 408-854-1603
  • Fax:
Mailing address:
  • Phone: 408-845-1603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1671
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: