Provider Demographics
NPI:1700230604
Name:GONZABA, MICHELLE RENAE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE
Last Name:GONZABA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:VAN HECKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8711 VILLAGE DR STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5419
Mailing Address - Country:US
Mailing Address - Phone:210-229-9282
Mailing Address - Fax:210-229-9283
Practice Address - Street 1:926 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1637
Practice Address - Country:US
Practice Address - Phone:201-229-9282
Practice Address - Fax:210-229-9283
Is Sole Proprietor?:No
Enumeration Date:2016-04-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR9966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine