Healthcare Provider Details

I. General information

NPI: 1619612132
Provider Name (Legal Business Name): VICTORIA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 10/23/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5303 HARRY HINES BLVD FL 4
DALLAS TX
75390-7208
US

IV. Provider business mailing address

5303 HARRY HINES BLVD
DALLAS TX
75390-7208
US

V. Phone/Fax

Practice location:
  • Phone: 214-645-8300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15454
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: