Provider Demographics
NPI:1891132940
Name:GONZALEZ, JESSI (PA)
Entity Type:Individual
Prefix:
First Name:JESSI
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 WEST 168TH STREET
Mailing Address - Street 2:CHONY NORTH B LEVEL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:212-305-1779
Mailing Address - Fax:
Practice Address - Street 1:622 WEST 168TH STREET
Practice Address - Street 2:CHONY NORTH B LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0165091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant