Provider Demographics
NPI:1639294002
Name:GONZALO, LORI (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:
Last Name:GONZALO
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 EMILY CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-2087
Mailing Address - Country:US
Mailing Address - Phone:718-966-1784
Mailing Address - Fax:718-966-1969
Practice Address - Street 1:2071 CLOVE RD
Practice Address - Street 2:GRASMERE MEDICAL PAVILLION
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1671
Practice Address - Country:US
Practice Address - Phone:718-442-5550
Practice Address - Fax:718-556-3025
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009282363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400003862Medicare PIN