MEDICARE: VICTOR ANSELMO GOMEZ PA

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	363AS0400X	Surgical Physician Assistant	607	SC
2	363A00000X	Physician Assistant	607	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083672737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTOR ANSELMO GOMEZ PA

Provider Business Mailing Address
First Line	:	PO BOX 6069
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29171-6069
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2728 SUNSET BLVD STE 400
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-4839
Country	:	US
Telephone Number	:	803-936-7095
Fax Number	:	803-936-7908

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	07/04/2025

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Directions to “ VICTOR ANSELMO GOMEZ PA” Practice Location

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