Provider Demographics
NPI:1871290783
Name:GONZALEZ, MANUEL (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 NEWLON RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72904-2126
Mailing Address - Country:US
Mailing Address - Phone:479-974-1270
Mailing Address - Fax:
Practice Address - Street 1:4105 NEWLON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-2126
Practice Address - Country:US
Practice Address - Phone:479-974-1270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0135455163W00000X
AR223630363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse