Provider Demographics
NPI:1881589539
Name:GONZALES, SAM ROBERT (CNA)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:ROBERT
Last Name:GONZALES
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5703
Mailing Address - Country:US
Mailing Address - Phone:530-460-4082
Mailing Address - Fax:530-273-5410
Practice Address - Street 1:159 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5703
Practice Address - Country:US
Practice Address - Phone:530-460-4082
Practice Address - Fax:530-273-9541
Is Sole Proprietor?:No
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01224031376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide