Basic Information
| Provider Information | |||||||||
| NPI: | 1104869429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | BERNADETH | ||||||||
| MiddleName: | TAGLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663662983 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11603 STATE AVE | ||||||||
| Address2: | SUITE G | ||||||||
| City: | MARYSVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982718465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606586800 | ||||||||
| FaxNumber: | 3606586819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 08/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00047444 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1042878 | 05 | WA | MEDICAID | 8495723 | 05 | WA | MEDICAID | 225508 | 01 | WA | L & I NUMBER | OTHER | 8868622 | 01 | WA | MEDICARE NUMBER | OTHER |