Provider Demographics
NPI:1467944785
Name:GRAJO, GONZALO EMMAN (LVN)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:EMMAN
Last Name:GRAJO
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 WESTWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-5841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2609 NESSUH AVE
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78541-4814
Practice Address - Country:US
Practice Address - Phone:956-630-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207164164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164Medicaid