Provider Demographics
NPI:1942366281
Name:GONZALES, YOODIY A (PA)
Entity type:Individual
Prefix:
First Name:YOODIY
Middle Name:A
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 N GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-4616
Mailing Address - Country:US
Mailing Address - Phone:909-524-0555
Mailing Address - Fax:909-524-0122
Practice Address - Street 1:822 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-4616
Practice Address - Country:US
Practice Address - Phone:909-524-0555
Practice Address - Fax:909-524-0122
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14560Medicaid