=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114164795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALLY GONZALES-APODACA C.P.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2009
-----------------------------------------------------
Last Update Date | 01/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1339 S PUEBLO BLVD
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81005-1686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-564-9400
-----------------------------------------------------
Fax | 719-564-0497
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1080 CHINOOK LN
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81001-1850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-564-9400
-----------------------------------------------------
Fax | 719-564-0497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 117
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------