Provider Demographics
NPI:1982461794
Name:GONZALEZ, YESENIA (PA-C)
Entity Type:Individual
Prefix:
First Name:YESENIA
Middle Name:
Last Name:GONZALEZ
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 1:874 BARNES CROSSING ROAD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-0909
Mailing Address - Country:US
Mailing Address - Phone:662-841-0002
Mailing Address - Fax:662-269-6346
Practice Address - Street 1:407 INTERCHANGE DR
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843-6029
Practice Address - Country:US
Practice Address - Phone:662-269-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant