Healthcare Provider Details

I. General information

NPI: 1639241805
Provider Name (Legal Business Name): FABIAN J GOMEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MADISON OAK DR
SAN ANTONIO TX
78258-3913
US

IV. Provider business mailing address

7703 FLOYD CURL DR # MC7977
SAN ANTONIO TX
78229-3901
US

V. Phone/Fax

Practice location:
  • Phone: 210-297-4000
  • Fax:
Mailing address:
  • Phone: 210-358-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05060
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: