Provider Demographics
NPI:1770273385
Name:GONZALES HERNANDEZ, ELMAN OTNIEL (PA)
Entity type:Individual
Prefix:
First Name:ELMAN
Middle Name:OTNIEL
Last Name:GONZALES HERNANDEZ
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SNAPDRAGON RD
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37876-5830
Mailing Address - Country:US
Mailing Address - Phone:865-384-1458
Mailing Address - Fax:
Practice Address - Street 1:2615 E WEST CONNECTOR STE 106
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6854
Practice Address - Country:US
Practice Address - Phone:770-941-0010
Practice Address - Fax:770-941-0154
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
GA12891363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program