Provider Demographics
NPI:1609849124
Name:GONZALES, JASON THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 LEAD AVE SE
Practice Address - Street 2:PMG GI
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-5215
Practice Address - Country:US
Practice Address - Phone:505-224-7000
Practice Address - Fax:505-224-7292
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2016-06-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMPA2005-0032363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ58359Medicare UPIN