MEDICARE: LESLIE A GONZALES FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	750702	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TXB159076	OTHER		WELLMED MEDICAL GROUP PA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063767572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE A GONZALES FNP-BC

Provider Business Mailing Address
First Line	:	19114 US HIGHWAY 281 N
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4988
Country	:	US
Telephone Number	:	210-496-7999
Fax Number	:	210-494-1666

Provider Business Practice Location Address
First Line	:	19114 US HIGHWAY 281 N
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4988
Country	:	US
Telephone Number	:	210-496-7999
Fax Number	:	210-494-1666

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2012
Last Update Date	:	02/22/2024

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