Healthcare Provider Details

I. General information

NPI: 1902229677
Provider Name (Legal Business Name): NINA M GOMEZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LINNIE CT
EDGEWOOD NM
87015-9125
US

IV. Provider business mailing address

PO BOX 896
EDGEWOOD NM
87015-0896
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-7838
  • Fax: 505-286-8025
Mailing address:
  • Phone: 505-286-7838
  • Fax: 505-286-8025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-1016
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: