Provider Demographics
NPI:1942484126
Name:GONZALEZ, WANDA DAMARIS
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:DAMARIS
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 CALLE CASTELLON
Mailing Address - Street 2:URB. VISTAMAR
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-1433
Mailing Address - Country:US
Mailing Address - Phone:787-646-4608
Mailing Address - Fax:787-752-2715
Practice Address - Street 1:CARR. 190 KM. 0.7
Practice Address - Street 2:MARGINAL BADORIOTY DE CASTRO
Practice Address - City:CAROLINA
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00985
Practice Address - Country:UM
Practice Address - Phone:787-646-4608
Practice Address - Fax:787-752-2715
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory