Healthcare Provider Details

I. General information

NPI: 1144382102
Provider Name (Legal Business Name): WILLIAM GOMEZ P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5953 ATLANTIC BLVD
MAYWOOD CA
90270-3133
US

IV. Provider business mailing address

5953 ATLANTIC BLVD
MAYWOOD CA
90270-3133
US

V. Phone/Fax

Practice location:
  • Phone: 323-562-6170
  • Fax: 323-562-6176
Mailing address:
  • Phone: 323-562-6170
  • Fax: 323-562-6176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: