Healthcare Provider Details

I. General information

NPI: 1578788071
Provider Name (Legal Business Name): MARY LOUISE GOMES TINDLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY LOUISE GOMES PHYSICIAN ASSISTANT

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 HYDE ST SUITE 322 DR JEROME GOLDSTEIN MD
SAN FRANCISCO CA
94109-4822
US

IV. Provider business mailing address

1332 CALIFORNIA ST APT 4
SAN FRANCISCO CA
94109-4964
US

V. Phone/Fax

Practice location:
  • Phone: 415-673-4600
  • Fax: 415-673-9532
Mailing address:
  • Phone: 415-474-9919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number18780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: