Provider Demographics
NPI:1265092555
Name:GONZALEZ, CHAD RENARD
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:RENARD
Last Name:GONZALEZ
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:PO BOX 3435
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20188-8035
Mailing Address - Country:US
Mailing Address - Phone:571-330-9204
Mailing Address - Fax:
Practice Address - Street 1:433 OLIVER CITY RD
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2018
Practice Address - Country:US
Practice Address - Phone:571-330-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002086874164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse