Provider Demographics
NPI:1679920946
Name:GONZALEZ, ROY (PTA)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 RIDGEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-4052
Mailing Address - Country:US
Mailing Address - Phone:712-204-4297
Mailing Address - Fax:
Practice Address - Street 1:40 RIDGEVIEW RD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-4052
Practice Address - Country:US
Practice Address - Phone:712-204-4297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1463313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility