MEDICARE: JENNIFER ALEXIS GONZALES PA

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	363AS0400X	Surgical Physician Assistant	PA1152	OK

General Provider Information

NPI Number	:	1366404030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER ALEXIS GONZALES PA

Provider Business Mailing Address
First Line	:	6802 S OLYMPIA AVE
Second Line	:	STE300
City	:	TULSA
State	:	OK
Zip	:	74132-1823
Country	:	US
Telephone Number	:	918-749-0762
Fax Number	:	918-744-4246

Provider Business Practice Location Address
First Line	:	6802 S OLYMPIA AVE
Second Line	:	STE300
City	:	TULSA
State	:	OK
Zip	:	74132-1823
Country	:	US
Telephone Number	:	918-749-0762
Fax Number	:	918-744-4246

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/13/2007

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