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General NPI Number Information
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NPI Number | 1265007819
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Entity Type | Individual
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Provider Name | NICOLETTE GONZALEZ PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/26/2021
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Last Update Date | 08/02/2024
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Provider Practice Location Address
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Address Line | 3900 5TH AVE
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City | SAN DIEGO
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State | CA
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Zip | 92103-3121
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Country | US
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Telephone | 858-554-1212
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Fax |
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Provider Business Mailing Address
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Address Line | 310 A ST APT 2102
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City | SAN DIEGO
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State | CA
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Zip | 92101-4323
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Country | US
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Telephone | 619-751-7765
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA63835
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License Number State | CA
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