Provider Demographics
NPI:1295453397
Name:GONZALES, BRIAN EDWARD (AGACNP-BC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:EDWARD
Last Name:GONZALES
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 SHAKERTOWN WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6048
Mailing Address - Country:US
Mailing Address - Phone:314-495-1237
Mailing Address - Fax:
Practice Address - Street 1:1600 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5897
Practice Address - Country:US
Practice Address - Phone:573-815-8000
Practice Address - Fax:573-815-2492
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022020263363LA2200X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty