Provider Demographics
NPI:1588225858
Name:GONZALES, TOMMY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11716 W WILKINSON ST
Mailing Address - Street 2:
Mailing Address - City:MAIZE
Mailing Address - State:KS
Mailing Address - Zip Code:67101-9007
Mailing Address - Country:US
Mailing Address - Phone:760-717-7257
Mailing Address - Fax:
Practice Address - Street 1:11716 W WILKINSON ST
Practice Address - Street 2:
Practice Address - City:MAIZE
Practice Address - State:KS
Practice Address - Zip Code:67101-9007
Practice Address - Country:US
Practice Address - Phone:760-717-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-014982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer