Provider Demographics
NPI:1487985016
Name:GONZALEZ, SERGIO (CRNA)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:SERGIO
Other - Middle Name:
Other - Last Name:GONZALEZ-CHAP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1011 14TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1828
Mailing Address - Country:US
Mailing Address - Phone:580-226-1251
Mailing Address - Fax:580-226-1254
Practice Address - Street 1:1011 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1828
Practice Address - Country:US
Practice Address - Phone:580-226-1251
Practice Address - Fax:580-226-1254
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0075019367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR0075019OtherCRNA LICENSE