Basic Information
Provider Information
NPI: 1003018177
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GONZALEZ
FirstName: NANCY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3998 FAIR RIDGE RD
Address2: SUITE 300
City: FAIRFAX
State: VA
PostalCode: 220332921
CountryCode: US
TelephoneNumber: 7032959360
FaxNumber: 7037669725
Practice Location
Address1: 4646 N MARINE DR
Address2:  
City: CHICAGO
State: IL
PostalCode: 60640
CountryCode: US
TelephoneNumber: 7738788700
FaxNumber: 7087830920
Other Information
ProviderEnumerationDate: 06/01/2007
LastUpdateDate: 03/20/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000XME 99735FLY Allopathic & Osteopathic PhysiciansAnesthesiology 
207L00000X036116486ILN Allopathic & Osteopathic PhysiciansAnesthesiology 

ID Information
IDTypeStateIssuerDescription
03611648605IL MEDICAID


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