Provider Demographics
NPI:1740792795
Name:GONZALEZ, MARIO ALBERTO (MSN/FNP)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ALBERTO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MSN/FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27373 FAWN RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-8413
Mailing Address - Country:US
Mailing Address - Phone:562-278-4727
Mailing Address - Fax:
Practice Address - Street 1:651 N STATE ST STE 5
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-6574
Practice Address - Country:US
Practice Address - Phone:951-487-8506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007892363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily