Provider Demographics
NPI:1427306067
Name:GONZALEZ, MIGUEL (PA-C)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
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 1:126 E ZORANNE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2894
Mailing Address - Country:US
Mailing Address - Phone:956-456-4423
Mailing Address - Fax:
Practice Address - Street 1:126 E ZORANNE DR
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2894
Practice Address - Country:US
Practice Address - Phone:956-456-4423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015944363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant