Provider Demographics
NPI:1689697278
Name:GONZALEZ, JESUS (PA-C)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14906 PARAMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-3409
Mailing Address - Country:US
Mailing Address - Phone:562-630-1991
Mailing Address - Fax:562-630-0145
Practice Address - Street 1:14906 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-3409
Practice Address - Country:US
Practice Address - Phone:562-630-1991
Practice Address - Fax:562-630-0145
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15959Medicaid