Provider Demographics
NPI:1003524158
Name:GONZALEZ, KETSIA (MD)
Entity Type:Individual
Prefix:
First Name:KETSIA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KETSIA
Other - Middle Name:
Other - Last Name:GONZALEZ VAZQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:219 BO CHINO
Mailing Address - Street 2:
Mailing Address - City:VILLALBA
Mailing Address - State:PR
Mailing Address - Zip Code:00766-3002
Mailing Address - Country:US
Mailing Address - Phone:872-674-4784
Mailing Address - Fax:
Practice Address - Street 1:2225 PONCE BYPASS EDIFICIO PARRA SUITE 603
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-0071
Practice Address - Country:US
Practice Address - Phone:787-492-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1035363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical