Provider Demographics
NPI:1801398219
Name:GONZALEZ, AUDREY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2446 CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-5325
Mailing Address - Country:US
Mailing Address - Phone:832-607-0486
Mailing Address - Fax:
Practice Address - Street 1:3230 INTERSTATE 30 STE 100
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2662
Practice Address - Country:US
Practice Address - Phone:972-682-1791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty