Provider Demographics
NPI:1508276973
Name:GONZALES, STEPHANIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12241 ACADEMY RD NE STE 204
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-938-4214
Mailing Address - Fax:505-944-7720
Practice Address - Street 1:12241 ACADEMY RD NE STE 204
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111
Practice Address - Country:US
Practice Address - Phone:505-938-4214
Practice Address - Fax:505-944-7720
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant