Provider Demographics
NPI:1891148524
Name:AUSQUI, GONZALO
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:AUSQUI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 LEHIGH ST
Mailing Address - Street 2:APT # 415
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18042-3860
Mailing Address - Country:US
Mailing Address - Phone:702-272-6211
Mailing Address - Fax:
Practice Address - Street 1:2040 LEHIGH ST
Practice Address - Street 2:APT # 415
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042-3860
Practice Address - Country:US
Practice Address - Phone:702-272-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT212256208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery