Provider Demographics
NPI:1881158400
Name:GONZALEZ, STEPHANIE ESTER (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ESTER
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ESTER
Other - Last Name:KATZNELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 PEGGY CV
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-4453
Mailing Address - Country:US
Mailing Address - Phone:845-499-6264
Mailing Address - Fax:
Practice Address - Street 1:4900 MUELLER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3051
Practice Address - Country:US
Practice Address - Phone:512-324-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY743608555-00OtherFIDELITY CARE