Provider Demographics
NPI:1538424445
Name:GONZALEZ, JESUS R JR (PA)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:R
Last Name:GONZALEZ
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:R
Other - Last Name:GONZALEZ
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1901 S 1ST ST STE 600
Mailing Address - Street 2:MCALLEN
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-1228
Mailing Address - Country:US
Mailing Address - Phone:956-631-6136
Mailing Address - Fax:956-631-6136
Practice Address - Street 1:1901 S 1ST ST STE 600
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1228
Practice Address - Country:US
Practice Address - Phone:956-631-6136
Practice Address - Fax:956-631-6136
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX335076101Medicaid
TXPA07786OtherTEXAS MEDICAL BOARD
TX327681YY7UMedicare PIN