Provider Demographics
NPI:1366404030
Name:GONZALES, JENNIFER ALEXIS (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALEXIS
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6802 S OLYMPIA AVE
Mailing Address - Street 2:STE300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-1823
Mailing Address - Country:US
Mailing Address - Phone:918-749-0762
Mailing Address - Fax:918-744-4246
Practice Address - Street 1:6802 S OLYMPIA AVE
Practice Address - Street 2:STE300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1823
Practice Address - Country:US
Practice Address - Phone:918-749-0762
Practice Address - Fax:918-744-4246
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1152363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical