Provider Demographics
NPI:1164905121
Name:GONZALES, JONARD YLARDE
Entity Type:Individual
Prefix:
First Name:JONARD
Middle Name:YLARDE
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8432 CAMBRIA CELLARS CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-7164
Mailing Address - Country:US
Mailing Address - Phone:702-493-6071
Mailing Address - Fax:
Practice Address - Street 1:6240 N DURANGO DR STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-3941
Practice Address - Country:US
Practice Address - Phone:954-923-7440
Practice Address - Fax:954-923-1299
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV813530363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250005414Medicaid