Provider Demographics
NPI:1881234631
Name:GONZALEZ, PATRISA (APRN)
Entity type:Individual
Prefix:
First Name:PATRISA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:6 RICHLAND MEDICAL PARK DR STE 2100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6864
Practice Address - Country:US
Practice Address - Phone:803-434-2762
Practice Address - Fax:803-434-2713
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23584207RA0001X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP6638Medicaid