Basic Information
| Provider Information | |||||||||
| NPI: | 1508829813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848491 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752848491 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 140 HILLCREST MEDICAL BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767128897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542028980 | ||||||||
| FaxNumber: | 2547302692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00970 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8N9131 | 01 | TX | BLUE SHIELD | OTHER |