Provider Demographics
NPI:1376853192
Name:GONZALEZ, MARISA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3021
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-8321
Mailing Address - Country:US
Mailing Address - Phone:626-321-5311
Mailing Address - Fax:
Practice Address - Street 1:535 N ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3405
Practice Address - Country:US
Practice Address - Phone:626-321-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20634OtherPHYSICIAN ASSISTANT CERTIFICATE NO.