Provider Demographics
NPI:1649731852
Name:GONZALEZ, MARCIE
Entity type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:GONZALEZ
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 1:7010 S YALE AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-5743
Mailing Address - Country:US
Mailing Address - Phone:918-236-4179
Mailing Address - Fax:
Practice Address - Street 1:7010 S YALE AVE STE 215
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5743
Practice Address - Country:US
Practice Address - Phone:918-236-4179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100733450AMedicaid