Provider Demographics
NPI:1447507041
Name:GOMEZ, JESSICA (PA-C)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6820 PORTILLO ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-3832
Mailing Address - Country:US
Mailing Address - Phone:305-431-7906
Mailing Address - Fax:305-666-7983
Practice Address - Street 1:14701 NW 77TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-2500
Practice Address - Country:US
Practice Address - Phone:305-669-2833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9106649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant