Provider Demographics
NPI:1639775166
Name:GONZALES, PATRICK JORDAN (NP)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:JORDAN
Last Name:GONZALES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8759 CELEBRATION ST
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91708-8876
Mailing Address - Country:US
Mailing Address - Phone:909-217-8166
Mailing Address - Fax:
Practice Address - Street 1:8759 CELEBRATION ST
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91708-8876
Practice Address - Country:US
Practice Address - Phone:909-217-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015671363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95015671OtherNURSE PRACTITIONER FURNISHING NUMNBER