Provider Demographics
NPI:1205215027
Name:GONZALEZ, JUAN CARLOS SR
Entity Type:Individual
Prefix:
First Name:JUAN CARLOS
Middle Name:
Last Name:GONZALEZ
Suffix:SR
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 1:2780 S JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5628
Mailing Address - Country:US
Mailing Address - Phone:702-778-0830
Mailing Address - Fax:702-538-8100
Practice Address - Street 1:2780 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5628
Practice Address - Country:US
Practice Address - Phone:702-778-0830
Practice Address - Fax:702-538-8100
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV823386363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health