Basic Information
| Provider Information | |||||||||
| NPI: | 1972505717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY MEDICINE ASSOCIATES OF EL PASO, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9398 VISCOUNT BLVD STE 4C | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799258028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155941033 | ||||||||
| FaxNumber: | 9155941263 | ||||||||
| Practice Location | |||||||||
| Address1: | 9398 VISCOUNT BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799258056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155941033 | ||||||||
| FaxNumber: | 9155941263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9155941033 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 085498601 | 05 | TX | MEDICAID |