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General NPI Number Information
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NPI Number | 1699005538
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Entity Type | Individual
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Provider Name | JOHNNY EDWARD GOMEZ PA-C
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Gender | Male
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Dates
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Enumeration Date | 12/27/2009
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Last Update Date | 11/17/2023
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Provider Practice Location Address
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Address Line | 2250 NW 136TH AVE STE 100
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City | PEMBROKE PINES
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State | FL
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Zip | 33028-2628
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Country | US
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Telephone | 954-302-7960
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Fax | 954-628-5084
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Provider Business Mailing Address
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Address Line | 2250 NW 136TH AVE STE 100
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City | PEMBROKE PINES
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State | FL
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Zip | 33028-2628
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Country | US
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Telephone | 954-302-7960
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Fax | 954-628-5084
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9105188
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License Number State | FL
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