Provider Demographics
NPI:1174124929
Name:GONZALEZ, GRACE MARIE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RODRIGUEZ OLMO CALLE ARMANDO VEGA COLON
Mailing Address - Street 2:NO. 25
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612
Mailing Address - Country:US
Mailing Address - Phone:939-491-0265
Mailing Address - Fax:
Practice Address - Street 1:RODRIGUEZ OLMO, CALLE ARMANDO VEGA COLON
Practice Address - Street 2:NUMERO 25
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:939-491-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000539-PA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR000539-PAOtherLICENCE