Provider Demographics
NPI:1043811466
Name:GONZALEZ, DEANNA
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 GAULT TRL SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-3702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MSC10 5610 1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-2409
Practice Address - Country:US
Practice Address - Phone:505-272-4161
Practice Address - Fax:505-272-2776
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMDR-8089208600000X
390200000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208600000XAllopathic & Osteopathic PhysiciansSurgery