Provider Demographics
NPI:1770871576
Name:REY, MARY IRENE GONZALES (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARY IRENE
Middle Name:GONZALES
Last Name:REY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY IRENE
Other - Middle Name:GONZALES
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3699
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-8699
Mailing Address - Country:US
Mailing Address - Phone:657-241-3600
Mailing Address - Fax:657-241-7708
Practice Address - Street 1:4950 BARRANCA PKWY STE 104
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-8644
Practice Address - Country:US
Practice Address - Phone:949-857-1248
Practice Address - Fax:949-559-1165
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16685225100000X
CA21825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB275687OtherMEDICARE
CAP01319747OtherMEDICARE RAILROAD