Healthcare Provider Details

I. General information

NPI: 1386452084
Provider Name (Legal Business Name): GARY RONALD GOMEZ GARCIA FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2024
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79440 CORPORATE CENTER DR STE 108
LA QUINTA CA
92253-7243
US

IV. Provider business mailing address

79440 CORPORATE CENTER DR STE 108
LA QUINTA CA
92253-7243
US

V. Phone/Fax

Practice location:
  • Phone: 760-564-0902
  • Fax: 760-406-6039
Mailing address:
  • Phone: 760-564-0902
  • Fax: 760-406-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95033220
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: