Provider Demographics
NPI:1316741259
Name:GONZALEZ, KELLY (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 ASHLAND PL APT 21L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-4318
Mailing Address - Country:US
Mailing Address - Phone:347-861-9543
Mailing Address - Fax:
Practice Address - Street 1:160 CONVENT AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-9198
Practice Address - Country:US
Practice Address - Phone:212-650-7746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant