Provider Demographics
NPI:1487302170
Name:GONZALEZ, MARCO ANTONIO
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 E CALDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-7605
Mailing Address - Country:US
Mailing Address - Phone:559-732-4726
Mailing Address - Fax:559-732-4747
Practice Address - Street 1:221 E CALDWELL AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-7605
Practice Address - Country:US
Practice Address - Phone:559-732-4726
Practice Address - Fax:559-732-4726
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-13
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015923363LF0000X
CA95024226363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty