Provider Demographics
NPI:1467805796
Name:GONZALEZ, ASTI
Entity Type:Individual
Prefix:
First Name:ASTI
Middle Name:
Last Name:GONZALEZ
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 1:1112 KENTUCKY ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4943
Mailing Address - Country:US
Mailing Address - Phone:909-549-6034
Mailing Address - Fax:
Practice Address - Street 1:1112 KENTUCKY ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4943
Practice Address - Country:US
Practice Address - Phone:909-549-6034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF15014322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer