Provider Demographics
NPI:1588766919
Name:GONZALES, DAVID T (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:GONZALES
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 1:1015 S JENNINGS AVE APT 1200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3928
Practice Address - Country:US
Practice Address - Phone:817-731-0801
Practice Address - Fax:817-731-8468
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287991801Medicaid
TXTXB124153Medicare PIN
TXQ79634Medicare UPIN
TX8J4915Medicare PIN
TXTXB144272Medicare PIN