Provider Demographics
NPI:1124055389
Name:GONZALES, GUSTAVO (APN,C)
Entity type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:APN,C
Other - Prefix:
Other - First Name:GUSTAVO
Other - Middle Name:
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25-27 E DICKERSON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07801-4655
Mailing Address - Country:US
Mailing Address - Phone:973-361-0750
Mailing Address - Fax:
Practice Address - Street 1:25-27 E DICKERSON ST STE 101
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-4655
Practice Address - Country:US
Practice Address - Phone:973-361-0750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00106400363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health