Provider Demographics
NPI:1316345101
Name:GONZALEZ, MYRIAM (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MYRIAM
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:956-794-8853
Mailing Address - Fax:956-795-4744
Practice Address - Street 1:10710 MCPHERSON RD STE 300
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-6411
Practice Address - Country:US
Practice Address - Phone:956-794-8853
Practice Address - Fax:956-795-4744
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127049363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX342275001Medicaid
TX8990NMOtherBCBS