Provider Demographics
NPI:1457819104
Name:GONZALES MARTINEZ, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:GONZALES MARTINEZ
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:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78505-0306
Mailing Address - Country:US
Mailing Address - Phone:956-971-8800
Mailing Address - Fax:956-971-8804
Practice Address - Street 1:110 E SAVANNAH AVE STE 103
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1241
Practice Address - Country:US
Practice Address - Phone:956-971-8800
Practice Address - Fax:956-971-8804
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8KZ207OtherSOLO BCBS
TXP02274362OtherRR MEDICARE
TX398943601Medicaid
TX813835OtherMEDICARE LINKED TO PROVIDENCE MEDICAL