Healthcare Provider Details

I. General information

NPI: 1871020255
Provider Name (Legal Business Name): TINA MARIE GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 SAINT MICHAELS DR
SANTA FE NM
87505-7641
US

IV. Provider business mailing address

166 COUNTY ROAD 119
ESPANOLA NM
87532-3502
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-2049
  • Fax: 505-992-2930
Mailing address:
  • Phone: 505-501-4408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-03228
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: