Provider Demographics
NPI:1821163239
Name:GONZALES, FIDENCIO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:FIDENCIO
Middle Name:
Last Name:GONZALES
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 1:19141 STONE OAK PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3367
Mailing Address - Country:US
Mailing Address - Phone:210-268-0129
Mailing Address - Fax:210-311-4609
Practice Address - Street 1:14800 SAN PEDRO AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3733
Practice Address - Country:US
Practice Address - Phone:210-582-6600
Practice Address - Fax:210-582-6601
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03153363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA03153OtherLICENSE
TX8L4840Medicare PIN
PA03153OtherLICENSE