Provider Demographics
NPI:1477391357
Name:GONZALES, PADEN
Entity type:Individual
Prefix:
First Name:PADEN
Middle Name:
Last Name:GONZALES
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 1:1313 ANTELOPE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5865
Mailing Address - Country:US
Mailing Address - Phone:208-420-7270
Mailing Address - Fax:
Practice Address - Street 1:207 E 12TH ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3626
Practice Address - Country:US
Practice Address - Phone:208-365-1065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant