Healthcare Provider Details

I. General information

NPI: 1770864134
Provider Name (Legal Business Name): ANNY PATRICIA GONZALEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNY HICKMAN PA

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 ADA ST
SAN ANTONIO TX
78223-1703
US

IV. Provider business mailing address

PO BOX 734812
DALLAS TX
75373-4812
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-5515
  • Fax: 210-358-5530
Mailing address:
  • Phone: 210-358-9501
  • Fax: 210-358-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA TEMP LICENSE
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA07470
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA07470
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: