Healthcare Provider Details

I. General information

NPI: 1194651596
Provider Name (Legal Business Name): MATTHEW GOMEZ RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W BROADWAY ST
PECULIAR MO
64078-2503
US

IV. Provider business mailing address

416 W BROADWAY ST
PECULIAR MO
64078-2503
US

V. Phone/Fax

Practice location:
  • Phone: 816-547-0305
  • Fax:
Mailing address:
  • Phone: 816-547-0305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number2026026512
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: