=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861410490
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTONIO J GOMES JR. PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 UPPER RIVERDALE RD SW
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-994-9326
-----------------------------------------------------
Fax | 770-994-4747
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 PEACHTREE ST., NE NORTH TOWER, SUITE 2100
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30303-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-994-9326
-----------------------------------------------------
Fax | 770-994-4747
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 3486
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------