Provider Demographics
NPI:1093070039
Name:GONZALEZ, ALEXIS A (MA)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W 49TH ST
Mailing Address - Street 2:SUITE # 438
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3402
Mailing Address - Country:US
Mailing Address - Phone:305-439-0130
Mailing Address - Fax:305-823-0802
Practice Address - Street 1:900 W 49TH ST
Practice Address - Street 2:SUITE # 438
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3402
Practice Address - Country:US
Practice Address - Phone:305-439-0130
Practice Address - Fax:305-823-0802
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA64745172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker