Provider Demographics
NPI:1457821662
Name:GONZALEZ, AMANDA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1387 GEORGE DIETER DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7410
Mailing Address - Country:US
Mailing Address - Phone:915-275-0224
Mailing Address - Fax:915-275-0225
Practice Address - Street 1:1387 GEORGE DIETER DR BLDG B
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7410
Practice Address - Country:US
Practice Address - Phone:915-275-0224
Practice Address - Fax:915-275-0225
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant