Healthcare Provider Details

I. General information

NPI: 1659095594
Provider Name (Legal Business Name): ANDRE JAYLAN GOMEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 13TH ST
OKLAHOMA CITY OK
73104-5004
US

IV. Provider business mailing address

123 NE 2ND ST APT 311
OKLAHOMA CITY OK
73104-2264
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4700
  • Fax:
Mailing address:
  • Phone: 575-390-4202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4953
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4953
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberPA4953
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: