Provider Demographics
NPI:1326072950
Name:GONZALES, LIONEL MADRID JR (PA)
Entity Type:Individual
Prefix:
First Name:LIONEL
Middle Name:MADRID
Last Name:GONZALES
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W. STEWART DRIVE
Mailing Address - Street 2:SUITE 503
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3856
Mailing Address - Country:US
Mailing Address - Phone:714-997-2224
Mailing Address - Fax:714-997-1187
Practice Address - Street 1:1310 W STEWART DR
Practice Address - Street 2:SUITE 503
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3854
Practice Address - Country:US
Practice Address - Phone:714-997-2224
Practice Address - Fax:714-997-1187
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10115363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA10115OtherSTATE LICENSE
WPA10115AMedicare ID - Type Unspecified
R22396Medicare UPIN