Provider Demographics
NPI:1427574235
Name:GONZALEZ, MARISSA (IDMT)
Entity Type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:MISS
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2105 W BOONE AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2901
Mailing Address - Country:US
Mailing Address - Phone:210-995-5051
Mailing Address - Fax:
Practice Address - Street 1:UNIT 5071
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328-5071
Practice Address - Country:US
Practice Address - Phone:210-475-2413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians