Provider Demographics
NPI:1285750984
Name:GONZALES, MADELEINE (RPA)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 WATERS PL
Mailing Address - Street 2:EXECUTIVE OFFICE
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2723
Mailing Address - Country:US
Mailing Address - Phone:718-409-9450
Mailing Address - Fax:
Practice Address - Street 1:260 E 161ST ST
Practice Address - Street 2:MELROSE TRACK
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3512
Practice Address - Country:US
Practice Address - Phone:718-993-3397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004028363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00245643Medicaid