Provider Demographics
NPI:1578506390
Name:GONZALES, JEFFREY MICHAEL (FNP C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:GONZALES
Suffix:
Gender:M
Credentials:FNP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:1253 NW CANAL BLVD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1334
Practice Address - Country:US
Practice Address - Phone:541-548-8131
Practice Address - Fax:541-526-6608
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04764363L00000X
IAA-103474363L00000X
OR200650104NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5971GOOtherBSWA
WA0213580OtherLIWA
WA8187320Medicaid
WAG8862997Medicare PIN
WA5971GOOtherBSWA
WA8187320Medicaid
LA4H682CG97Medicare PIN