Provider Demographics
NPI:1841426822
Name:GONZALEZ, OTONIEL (NP)
Entity Type:Individual
Prefix:MR
First Name:OTONIEL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25621 ASHBY WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6003
Mailing Address - Country:US
Mailing Address - Phone:949-380-3009
Mailing Address - Fax:949-380-3009
Practice Address - Street 1:25621 ASHBY WAY
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6003
Practice Address - Country:US
Practice Address - Phone:949-380-3009
Practice Address - Fax:949-380-3009
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 16527363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner