Provider Demographics
NPI:1740506765
Name:GONZALES, ISAAC
Entity type:Individual
Prefix:
First Name:ISAAC
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:PO BOX 866
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-0866
Mailing Address - Country:US
Mailing Address - Phone:505-565-1619
Mailing Address - Fax:505-565-1620
Practice Address - Street 1:303 LUNA ST SE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-9277
Practice Address - Country:US
Practice Address - Phone:505-565-1619
Practice Address - Fax:505-565-1620
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator