Provider Demographics
NPI:1649348921
Name:GONZAGA, JESSE (NP)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:GONZAGA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 SUMMIT ST FL 2
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3480
Mailing Address - Country:US
Mailing Address - Phone:510-869-8660
Mailing Address - Fax:
Practice Address - Street 1:350 HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3108
Practice Address - Country:US
Practice Address - Phone:510-869-8660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11763363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP17840Medicare UPIN