Healthcare Provider Details

I. General information

NPI: 1851014013
Provider Name (Legal Business Name): CRISTAL GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-1680
US

IV. Provider business mailing address

3150 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-1680
US

V. Phone/Fax

Practice location:
  • Phone: 505-663-6343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: