Provider Demographics
NPI:1649899600
Name:GONZALES, KACIE WALLACE
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:WALLACE
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 1:6270 DILLY SHAW TAP RD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77808-8624
Mailing Address - Country:US
Mailing Address - Phone:979-450-5422
Mailing Address - Fax:
Practice Address - Street 1:2805 EARL RUDDER FWY S
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6080
Practice Address - Country:US
Practice Address - Phone:979-764-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14298363A00000X
OK3181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant