Provider Demographics
NPI:1598089997
Name:GONZALES, NICOLE ALICIA (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALICIA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-474-4780
Mailing Address - Fax:336-718-8941
Practice Address - Street 1:207 OLD LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3428
Practice Address - Country:US
Practice Address - Phone:336-474-4780
Practice Address - Fax:336-718-8941
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111874207R00000X
NC2019-02329207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine