Healthcare Provider Details

I. General information

NPI: 1013670413
Provider Name (Legal Business Name): LISA GONZALEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. N/A N/A

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
SAN ANTONIO TX
78234-4504
US

IV. Provider business mailing address

13326 GALICIA
UNIVERSAL CITY TX
78148-2709
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-4877
  • Fax:
Mailing address:
  • Phone: 210-325-7992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number594827
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: