Basic Information
| Provider Information | |||||||||
| NPI: | 1477109700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JUAN CARLOS | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER | ||||||||
| Address2: | MSC09-5030 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER | ||||||||
| Address2: | MSC09-5030 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725428 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2019 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.