Provider Demographics
NPI:1205316759
Name:GONSALVES, STEPHEN G (FNP, PHD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:G
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:FNP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 CREEK VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850
Mailing Address - Country:US
Mailing Address - Phone:240-780-6799
Mailing Address - Fax:
Practice Address - Street 1:500 12TH ST SW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20536-5098
Practice Address - Country:US
Practice Address - Phone:240-853-5887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR136201363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care