Healthcare Provider Details

I. General information

NPI: 1558154120
Provider Name (Legal Business Name): JONATHAN GONZALEZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 UNSER BLVD SE
RIO RANCHO NM
87124-3392
US

IV. Provider business mailing address

1209 MOUNTAIN ROAD PL NE STE R
ALBUQUERQUE NM
87110-7845
US

V. Phone/Fax

Practice location:
  • Phone: 505-253-7878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number83773
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: