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NPI Code Detail

MEDICARE: ANTONIO GONZALES

MEDICARE: ANTONIO GONZALES
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
1171M00000XCase Manager/Care Coordinator
2175T00000XPeer Specialist2027UT

General Provider Information

NPI Number : 1194346205
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANTONIO GONZALES
Provider Business Mailing Address
First Line : 3269 S MAIN ST STE 230
Second Line :
City : SOUTH SALT LAKE
State : UT
Zip : 84115-3769
Country : US
Telephone Number : 801-935-4447
Fax Number :
Provider Business Practice Location Address
First Line : 3269 S MAIN ST STE 230
Second Line :
City : SOUTH SALT LAKE
State : UT
Zip : 84115-3769
Country : US
Telephone Number : 801-935-4447
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/29/2020
Last Update Date : 04/25/2023

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Directions to “ ANTONIO GONZALES ” Practice Location

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