Provider Demographics
NPI:1003497272
Name:GONZALES, FERMIN JR (CPSW, CCSS)
Entity Type:Individual
Prefix:
First Name:FERMIN
Middle Name:
Last Name:GONZALES
Suffix:JR
Gender:M
Credentials:CPSW, CCSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 MONTGOMERY BLVD NE # 5
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2468
Mailing Address - Country:US
Mailing Address - Phone:505-219-1919
Mailing Address - Fax:
Practice Address - Street 1:9201 MONTGOMERY BLVD NE # 5
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2468
Practice Address - Country:US
Practice Address - Phone:505-219-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1105175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist