Provider Demographics
NPI:1588373203
Name:GONZALEZ, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 GOVE ST
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1920
Mailing Address - Country:US
Mailing Address - Phone:617-569-5800
Mailing Address - Fax:617-568-4756
Practice Address - Street 1:2284 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3829
Practice Address - Country:US
Practice Address - Phone:978-369-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA8922363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty