Provider Demographics
NPI:1518694850
Name:GONZALEZ, MIGUEL ANGEL JR
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:GONZALEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S RANCHO DR STE E33
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4833
Mailing Address - Country:US
Mailing Address - Phone:702-483-6302
Mailing Address - Fax:702-483-6313
Practice Address - Street 1:1810 VERDE MIRADA DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-3843
Practice Address - Country:US
Practice Address - Phone:714-400-8596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2103801601OtherDRIVERS LICENSE