Provider Demographics
NPI:1093030512
Name:GONZALES, GEOFFREY M (PMHNP)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:M
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 NOGALITOS STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78225-2337
Mailing Address - Country:US
Mailing Address - Phone:210-533-0257
Mailing Address - Fax:210-534-0890
Practice Address - Street 1:3110 NOGALITOS STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78225-2337
Practice Address - Country:US
Practice Address - Phone:210-533-0257
Practice Address - Fax:210-534-0890
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP118923363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP118923OtherAPRN LICENSE
TX3138232Medicaid