Provider Demographics
NPI:1043540594
Name:GONZALES, RAYMOND LEE (CMA-I, CNA, HHA,DDCA)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:LEE
Last Name:GONZALES
Suffix:
Gender:M
Credentials:CMA-I, CNA, HHA,DDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 S 128TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-6025
Mailing Address - Country:US
Mailing Address - Phone:918-437-8156
Mailing Address - Fax:
Practice Address - Street 1:1623 S 128TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-6025
Practice Address - Country:US
Practice Address - Phone:918-437-8156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37V840760399376J00000X, 372500000X, 372600000X
OK37V615640107376K00000X
OK320178900107373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK544235569AOtherMEDICARE OKLAHOMA CLAIM NUMBER FOR JEFFREY ROSE