Provider Demographics
NPI:1457819765
Name:GONZALEZ, MARY SIOBHAN (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SIOBHAN
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:SIOBHAN
Other - Last Name:ENGLISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:485 MADISON AVE FL 8
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-5803
Mailing Address - Country:US
Mailing Address - Phone:646-395-9729
Mailing Address - Fax:
Practice Address - Street 1:485 MADISON AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-5803
Practice Address - Country:US
Practice Address - Phone:646-395-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342827363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily