Provider Demographics
NPI:1780791392
Name:GONZALES, AMY BREEDLOVE (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:BREEDLOVE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 CREST CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-9329
Mailing Address - Country:US
Mailing Address - Phone:512-618-2826
Mailing Address - Fax:
Practice Address - Street 1:1600 N INTERSTATE 35
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-6984
Practice Address - Country:US
Practice Address - Phone:512-618-2826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00658363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307772902Medicaid
TX307772901Medicaid
TXTXB165566Medicare PIN
TXTXB165599Medicare PIN