Provider Demographics
NPI:1083626816
Name:GONZALES, RICHARD JOSEPH SR (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:GONZALES
Suffix:SR
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:6913 LAURA ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4443
Mailing Address - Country:US
Mailing Address - Phone:909-574-2057
Mailing Address - Fax:
Practice Address - Street 1:1212 S FLOWER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-2123
Practice Address - Country:US
Practice Address - Phone:213-747-0634
Practice Address - Fax:213-747-5304
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA14646363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical