MEDICARE: MICHELLE RENAE GONZABA

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	207Q00000X	Family Medicine Physician	R9966	TX

General Provider Information

NPI Number	:	1700230604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE RENAE GONZABA

Provider Business Mailing Address
First Line	:	8711 VILLAGE DR STE 114
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-5419
Country	:	US
Telephone Number	:	210-229-9282
Fax Number	:	210-229-9283

Provider Business Practice Location Address
First Line	:	926 BROOKLYN AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78215-1637
Country	:	US
Telephone Number	:	201-229-9282
Fax Number	:	210-229-9283

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

Provider Enumeration Date	:	04/17/2016
Last Update Date	:	07/17/2019

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Directions to “ MICHELLE RENAE GONZABA ” Practice Location

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