Provider Demographics
NPI:1871552109
Name:GONZALEZ, BIENVENIDO (PA)
Entity type:Individual
Prefix:MR
First Name:BIENVENIDO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 BEAUMONT PL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-1611
Mailing Address - Country:US
Mailing Address - Phone:973-483-3722
Mailing Address - Fax:
Practice Address - Street 1:385 TREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1023
Practice Address - Country:US
Practice Address - Phone:973-676-1000
Practice Address - Fax:973-395-7016
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00004300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical