Provider Demographics
NPI:1306220405
Name:KONG GONZALEZ, KATHERINE JEAN
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JEAN
Last Name:KONG GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7050 N RECREATION AVE
Mailing Address - Street 2:101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-8001
Mailing Address - Country:US
Mailing Address - Phone:559-325-3515
Mailing Address - Fax:
Practice Address - Street 1:7050 N RECREATION AVE
Practice Address - Street 2:101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8001
Practice Address - Country:US
Practice Address - Phone:559-325-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20956363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner