Healthcare Provider Details

I. General information

NPI: 1992990436
Provider Name (Legal Business Name): ALYSSA GONZALES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 CABEZON BLVD SE STE 103
RIO RANCHO NM
87124-1514
US

IV. Provider business mailing address

8308 CONSTITUTION PL NE
ALBUQUERQUE NM
87110-7637
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-9570
  • Fax: 505-883-4163
Mailing address:
  • Phone: 505-883-9570
  • Fax: 505-883-4163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2005-0043
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: