Provider Demographics
NPI:1356005680
Name:GONZALES, LORETTA
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:GONZALES
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 1:10151 MONTGOMERY BLVD NE BLDG 1
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3670
Mailing Address - Country:US
Mailing Address - Phone:505-855-5503
Mailing Address - Fax:505-855-5533
Practice Address - Street 1:10151 MONTGOMERY BLVD NE BLDG 1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3670
Practice Address - Country:US
Practice Address - Phone:505-855-5503
Practice Address - Fax:505-855-5533
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2023-0232363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPA2023-0232OtherLICENSE