1164974705 NPI number — MR. FIDEL GONZALEZ MS, RN, ACNPC-AG

Table of content: MR. FIDEL GONZALEZ MS, RN, ACNPC-AG (NPI 1164974705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164974705 NPI number — MR. FIDEL GONZALEZ MS, RN, ACNPC-AG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
FIDEL
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS, RN, ACNPC-AG
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164974705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
755 N 11TH ST
Provider Second Line Business Mailing Address:
STE P3950
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77702-1527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-892-0099
Provider Business Mailing Address Fax Number:
409-892-1911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
755 N 11TH ST
Provider Second Line Business Practice Location Address:
SUITE P-3950
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77702-1500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-892-0099
Provider Business Practice Location Address Fax Number:
409-892-1911
Provider Enumeration Date:
10/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  AP132432 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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