Healthcare Provider Details

I. General information

NPI: 1669775102
Provider Name (Legal Business Name): MARTIN D GONZALEZ FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 N ACCESS RD
CLYDE TX
79510
US

IV. Provider business mailing address

PO BOX 2435
ALBANY TX
76430-8020
US

V. Phone/Fax

Practice location:
  • Phone: 325-893-4010
  • Fax: 325-893-4035
Mailing address:
  • Phone: 325-893-4010
  • Fax: 325-893-4035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number714984
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: