Basic Information
| Provider Information | |||||||||
| NPI: | 1942843107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | GRYSKA | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 16TH AVE E | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981125211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063263000 | ||||||||
| FaxNumber: | 2063262785 | ||||||||
| Practice Location | |||||||||
| Address1: | 11190 WARNER AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927084045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142417000 | ||||||||
| FaxNumber: | 7142417003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2019 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA57278 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA61139014 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.