Basic Information
| Provider Information | |||||||||
| NPI: | 1720210842 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | ALEXIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 S BROAD ST | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191483542 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2301 S BROAD ST | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191483542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159239323 | ||||||||
| FaxNumber: | 2159521246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2009 | ||||||||
| LastUpdateDate: | 03/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 26NR13112500 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367500000X | RN548175 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | NR13112500 | 01 | NJ | STATE LICENSE | OTHER |