Provider Demographics
NPI:1528601929
Name:GONZALES, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GONZALES
Suffix:
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:PSC 564 BOX 80
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96387-0001
Mailing Address - Country:US
Mailing Address - Phone:315-224-8381
Mailing Address - Fax:
Practice Address - Street 1:PSC 564 BOX 80
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96387-0001
Practice Address - Country:US
Practice Address - Phone:315-224-8381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman