Provider Demographics
NPI:1780289801
Name:GONZALES, ETHAN ISAIAH
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:ISAIAH
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 1:3141 CENTER POINT DR
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-8433
Mailing Address - Country:US
Mailing Address - Phone:956-618-1300
Mailing Address - Fax:
Practice Address - Street 1:3141 CENTER POINT DR
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-8433
Practice Address - Country:US
Practice Address - Phone:956-618-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant