Healthcare Provider Details

I. General information

NPI: 1023798519
Provider Name (Legal Business Name): MIZRAIM GOMEZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

903 W MARTIN ST
SAN ANTONIO TX
78207-0903
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-0572
  • Fax:
Mailing address:
  • Phone: 210-358-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1126946
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: