Provider Demographics
NPI:1992339592
Name:GONZALES, EMILY SUE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:SUE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:SUE
Other - Last Name:STATZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W129N7055 NORTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-0538
Mailing Address - Country:US
Mailing Address - Phone:262-253-5400
Mailing Address - Fax:
Practice Address - Street 1:W129N7055 NORTHFIELD DR
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-0538
Practice Address - Country:US
Practice Address - Phone:262-253-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5665-23363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant