MEDICARE: MR. MANUEL GONZALEZ 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	163W00000X	Registered Nurse	R0135455	OK
2	363LF0000X	Family Nurse Practitioner	223630	AR

General Provider Information

NPI Number	:	1871290783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MANUEL GONZALEZ FNP-BC

Provider Business Mailing Address
First Line	:	4105 NEWLON RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72904-2126
Country	:	US
Telephone Number	:	479-974-1270
Fax Number	:

Provider Business Practice Location Address
First Line	:	4105 NEWLON RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72904-2126
Country	:	US
Telephone Number	:	479-974-1270
Fax Number	:

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

Provider Enumeration Date	:	02/10/2023
Last Update Date	:	04/05/2023

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