Provider Demographics
NPI:1386480481
Name:GONZALEZ, EMMANUEL (PA)
Entity type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2636
Mailing Address - Country:US
Mailing Address - Phone:973-762-4720
Mailing Address - Fax:973-762-3731
Practice Address - Street 1:511 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2636
Practice Address - Country:US
Practice Address - Phone:973-762-4720
Practice Address - Fax:973-762-3731
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00861800363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical