MEDICARE: ANDRES MAURICIO GOMEZ JACOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	18-417	FL

General Provider Information

NPI Number	:	1053123166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDRES MAURICIO GOMEZ JACOME

Provider Business Mailing Address
First Line	:	800 N HOWARD AVE UNIT 352
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-1086
Country	:	US
Telephone Number	:	321-890-9170
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 N HOWARD AVE UNIT 352
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-1086
Country	:	US
Telephone Number	:	321-890-9170
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2025
Last Update Date	:	01/24/2025

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