Provider Demographics
NPI:1831412485
Name:GONZALEZ, OMAR J (PA-C)
Entity type:Individual
Prefix:MR
First Name:OMAR
Middle Name:J
Last Name:GONZALEZ
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:9200 SE 91ST AVE
Mailing Address - Street 2:STE 340
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97086-3756
Mailing Address - Country:US
Mailing Address - Phone:503-256-1462
Mailing Address - Fax:503-257-9523
Practice Address - Street 1:4011 TALBOT RD S
Practice Address - Street 2:SUITE 300
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5773
Practice Address - Country:US
Practice Address - Phone:425-656-5060
Practice Address - Fax:425-656-5047
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2023-02-09
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Provider Licenses
StateLicense IDTaxonomies
WAPA60133734363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant