MEDICARE: MS. MARY-SUTTON GONZALEZ

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	174400000X	Specialist

General Provider Information

NPI Number	:	1861740037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY-SUTTON GONZALEZ

Provider Business Mailing Address
First Line	:	20 COMMERCE ST
Second Line	:	APARTMENT 2D
City	:	NEW YORK
State	:	NY
Zip	:	10014-3752
Country	:	US
Telephone Number	:	813-447-9074
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 COMMERCE ST
Second Line	:	APARTMENT 2D
City	:	NEW YORK
State	:	NY
Zip	:	10014-3752
Country	:	US
Telephone Number	:	813-447-9074
Fax Number	:

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

Provider Enumeration Date	:	08/20/2012
Last Update Date	:	08/20/2012

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