Provider Demographics
NPI:1760212807
Name:GONZALES, NATHANIEL
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:GONZALES
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 1:5051 W HIGHLAND KNOLLS RD APT 218
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-3072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1125 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1908
Practice Address - Country:US
Practice Address - Phone:210-846-8174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program