Provider Demographics
NPI:1033702154
Name:GONSALVES, WARREN ANTONIO
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:ANTONIO
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4257 SAUBRANCH HILL ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5999
Mailing Address - Country:US
Mailing Address - Phone:919-306-1695
Mailing Address - Fax:
Practice Address - Street 1:4257 SAUBRANCH HILL ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-5999
Practice Address - Country:US
Practice Address - Phone:919-306-1695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health