Provider Demographics
NPI:1568136075
Name:GONZALEZ MIRANDA, ELIO
Entity Type:Individual
Prefix:
First Name:ELIO
Middle Name:
Last Name:GONZALEZ MIRANDA
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 1:4458 S STAPLES ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2602
Mailing Address - Country:US
Mailing Address - Phone:361-236-4382
Mailing Address - Fax:281-298-6655
Practice Address - Street 1:4458 S STAPLES ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2602
Practice Address - Country:US
Practice Address - Phone:361-236-4382
Practice Address - Fax:281-298-6655
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-07
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11014403164W00000X, 363LF0000X
TX1060018363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No164W00000XNursing Service ProvidersLicensed Practical Nurse