Provider Demographics
NPI:1013671882
Name:GONZALEZ, IRASEMA
Entity Type:Individual
Prefix:
First Name:IRASEMA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3284 VISTA TER
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5725 SOTO ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2630
Practice Address - Country:US
Practice Address - Phone:888-367-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant