Provider Demographics
NPI:1245329606
Name:GONZALES, VERONICA A (PA)
Entity type:Individual
Prefix:MS
First Name:VERONICA
Middle Name:A
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 RUSTIC WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1118
Mailing Address - Country:US
Mailing Address - Phone:925-779-9709
Mailing Address - Fax:
Practice Address - Street 1:36 RUSTIC WAY
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-1118
Practice Address - Country:US
Practice Address - Phone:925-779-9709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA318979600OtherDEPARTMENT OF LABOR
CA970013241OtherRAILROAD PROVIDER NUMBER
CAOPA124890OtherMC PTAN
CA900280949OtherEIN
CA318979600OtherDEPARTMENT OF LABOR