Provider Demographics
NPI:1649438664
Name:GONZALES, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
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 1:875 STATE HIGHWAY 217
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-7813
Mailing Address - Country:US
Mailing Address - Phone:505-832-5553
Mailing Address - Fax:505-832-5392
Practice Address - Street 1:875 STATE HIGHWAY 217
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-7813
Practice Address - Country:US
Practice Address - Phone:505-832-5553
Practice Address - Fax:505-832-5392
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker