Provider Demographics
NPI:1881278687
Name:GONZALES, WAIDE HICKS (PA-C)
Entity type:Individual
Prefix:
First Name:WAIDE
Middle Name:HICKS
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:WAIDE
Other - Middle Name:ANTHONY
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4352 DAYWALT RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-6011
Mailing Address - Country:US
Mailing Address - Phone:408-504-4051
Mailing Address - Fax:
Practice Address - Street 1:4352 DAYWALT RD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-6011
Practice Address - Country:US
Practice Address - Phone:408-504-4051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA60135363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program