Provider Demographics
NPI:1295797835
Name:GONZALES, LUCIO R JR (PA)
Entity type:Individual
Prefix:
First Name:LUCIO
Middle Name:R
Last Name:GONZALES
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-8509
Mailing Address - Country:US
Mailing Address - Phone:972-272-8578
Mailing Address - Fax:214-594-8723
Practice Address - Street 1:4109 PRESTON RD
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-8509
Practice Address - Country:US
Practice Address - Phone:972-272-8578
Practice Address - Fax:214-594-8723
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03821363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211128801Medicaid
TXQ19149Medicare UPIN
TX211128801Medicaid
TX351820YKP5Medicare PIN