Provider Demographics
NPI:1649466947
Name:GONZALES, LAURA A (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-4035
Mailing Address - Country:US
Mailing Address - Phone:940-382-9636
Mailing Address - Fax:940-382-1554
Practice Address - Street 1:700 W OAK ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-4035
Practice Address - Country:US
Practice Address - Phone:940-382-9636
Practice Address - Fax:940-382-1554
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX317142302Medicaid
TX317142301Medicaid
TX317142301Medicaid
TXTXB107121Medicare PIN