Provider Demographics
NPI:1316583362
Name:GONZALEZ, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name: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 1:1020 LAKE SUMTER LNDG
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-2699
Mailing Address - Country:US
Mailing Address - Phone:352-674-8905
Mailing Address - Fax:352-674-8901
Practice Address - Street 1:280 FARNER PL
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32163-6066
Practice Address - Country:US
Practice Address - Phone:352-674-1710
Practice Address - Fax:352-674-8910
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004626208VP0014X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine