Provider Demographics
NPI:1356443782
Name:OBUSAN-GONZALEZ, RACHELLE R (PA)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:R
Last Name:OBUSAN-GONZALEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7901 BROADWAY
Mailing Address - Street 2:ROOM A1-9
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-4952
Mailing Address - Fax:718-334-4815
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:ROOM A1-9
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-4952
Practice Address - Fax:718-334-4815
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY006394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant