Provider Demographics
NPI:1982888194
Name:GONZALEZ, MELISSA M (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MALTBY
Mailing Address - Street 1:2111 SW 20TH PL
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-7734
Mailing Address - Country:US
Mailing Address - Phone:352-622-4251
Mailing Address - Fax:352-547-3373
Practice Address - Street 1:2111 SW 20TH PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-7734
Practice Address - Country:US
Practice Address - Phone:352-622-4251
Practice Address - Fax:352-622-0102
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005222363AM0700X
FLPA9115402363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA299642022AMedicaid
GA511I970154Medicare PIN