Basic Information
| Provider Information | |||||||||
| NPI: | 1578506390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | FNP C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1253 NW CANAL BLVD | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415488131 | ||||||||
| FaxNumber: | 5415266608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 06/07/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP04764 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | A-103474 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 200650104NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 5971GO | 01 | WA | BSWA | OTHER | 0213580 | 01 | WA | LIWA | OTHER | 8187320 | 05 | WA | MEDICAID |