Provider Demographics
NPI:1770864134
Name:GONZALEZ, ANNY PATRICIA (PA)
Entity Type:Individual
Prefix:
First Name:ANNY
Middle Name:PATRICIA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANNY
Other - Middle Name:
Other - Last Name:HICKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 734812
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4812
Mailing Address - Country:US
Mailing Address - Phone:210-358-9501
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:1055 ADA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-1703
Practice Address - Country:US
Practice Address - Phone:210-358-5515
Practice Address - Fax:210-358-5530
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA TEMP LICENSE363A00000X
TXPA07470363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA TEMP LICENSEOtherTEMPORARY LICENSE
TX12284275OtherCAQH