Basic Information
| Provider Information | |||||||||
| NPI: | 1184202426 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JOHAN-R | ||||||||
| MiddleName: | LOMELI | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255228 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666810736 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 SPANOS CT STE 111 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095504779 | ||||||||
| FaxNumber: | 2094917508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2021 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA59776 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.