Provider Demographics
NPI:1679350896
Name:GONZALEZ, ELIDA
Entity Type:Individual
Prefix:
First Name:ELIDA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6542
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93456-6542
Mailing Address - Country:US
Mailing Address - Phone:805-714-7515
Mailing Address - Fax:
Practice Address - Street 1:430 S BLOSSER RD
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-4908
Practice Address - Country:US
Practice Address - Phone:805-361-8900
Practice Address - Fax:805-361-8990
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical