Healthcare Provider Details

I. General information

NPI: 1518321173
Provider Name (Legal Business Name): ANDREW GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1077 COMSTOCK AVE
SYRACUSE NY
13244-0001
US

IV. Provider business mailing address

4720 LINDA DR
SYRACUSE NY
13215-2118
US

V. Phone/Fax

Practice location:
  • Phone: 315-443-2085
  • Fax: 315-443-5057
Mailing address:
  • Phone: 630-338-2334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number004553
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: