Healthcare Provider Details

I. General information

NPI: 1659263960
Provider Name (Legal Business Name): JUAN A GONZALEZ FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

1538 AVENIDA DE LAS AMERICAS APT B
SANTA FE NM
87507-5191
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-0295
  • Fax:
Mailing address:
  • Phone: 505-913-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number56511
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: