Provider Demographics
NPI:1972522779
Name:GONZALEZ, EUGENIO DE JESUS (PAC)
Entity Type:Individual
Prefix:MR
First Name:EUGENIO
Middle Name:DE JESUS
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 MILITARY CUTOFF RD STE 103
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3685
Mailing Address - Country:US
Mailing Address - Phone:910-256-6222
Mailing Address - Fax:
Practice Address - Street 1:4402 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6161
Practice Address - Country:US
Practice Address - Phone:910-452-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC103739363AM0700X
NC103739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1972522779Medicaid
SC0932PAMedicaid
NCMG0980690OtherDEA
NC1972522779Medicaid
SC0932PAMedicaid
NCNC4590FMedicare PIN
NCNC4590DMedicare PIN