Provider Demographics
NPI:1043034853
Name:GONZALEZ, NIKO
Entity type:Individual
Prefix:
First Name:NIKO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 CHESTNUT HILL AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-4652
Mailing Address - Country:US
Mailing Address - Phone:214-476-4653
Mailing Address - Fax:
Practice Address - Street 1:780 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3908
Practice Address - Country:US
Practice Address - Phone:214-476-4653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-09
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program