Provider Demographics
NPI:1285715094
Name:GONZAGA, DOROTHY G (ARNP)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:G
Last Name:GONZAGA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 S CEDAR ST STE 330
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2318
Mailing Address - Country:US
Mailing Address - Phone:253-272-5127
Mailing Address - Fax:
Practice Address - Street 1:2202 S CEDAR ST STE 330
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2318
Practice Address - Country:US
Practice Address - Phone:253-272-5127
Practice Address - Fax:253-272-0811
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007463363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30007463OtherWA LICENSE
WA9651001Medicaid
WAAP30007463OtherWA LICENSE
WAP00424496Medicare PIN
WA8851594Medicare PIN
WA9651001Medicaid
WAG8851595Medicare PIN
WAG8851597Medicare PIN
WAG8851594Medicare PIN
WA8867061Medicare PIN
WA000188100Medicare PIN
WAG8880511Medicare PIN
WA8867060Medicare PIN