Basic Information
| Provider Information | |||||||||
| NPI: | 1194702787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | NESTOR | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1323 | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095472204 | ||||||||
| FaxNumber: | 5095428836 | ||||||||
| Practice Location | |||||||||
| Address1: | 5219 WEST CLEARWATER AVENUE | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097834454 | ||||||||
| FaxNumber: | 5097836601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00042850 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8385338 | 05 | WA | MEDICAID |