Provider Demographics
NPI:1356416788
Name:GONZALEZ, MATTHEW WAYNE (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WAYNE
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PERKINS DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3248
Mailing Address - Country:US
Mailing Address - Phone:505-523-7243
Mailing Address - Fax:505-523-7254
Practice Address - Street 1:301 PERKINS DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3248
Practice Address - Country:US
Practice Address - Phone:505-523-7243
Practice Address - Fax:505-523-7254
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist