Provider Demographics
NPI:1336790070
Name:GONZALES, JOE (ARNP)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:
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:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541-9285
Practice Address - Country:US
Practice Address - Phone:360-861-8700
Practice Address - Fax:360-861-8711
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00166711163W00000X
WAAP61417695363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2141682Medicaid