Provider Demographics
NPI:1609385756
Name:GONZALEZ, ABRAHAM ISACC (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:ISACC
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-4618
Mailing Address - Country:US
Mailing Address - Phone:951-488-8649
Mailing Address - Fax:
Practice Address - Street 1:255 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405
Practice Address - Country:US
Practice Address - Phone:951-488-8649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA825669163WC0200X
CA95000872367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine