MEDICARE: MS. JESSICA GOMEZ PA-C

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	363A00000X	Physician Assistant	PA 9106649	FL

General Provider Information

NPI Number	:	1447507041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JESSICA GOMEZ PA-C

Provider Business Mailing Address
First Line	:	6820 PORTILLO ST
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-3832
Country	:	US
Telephone Number	:	305-431-7906
Fax Number	:	305-666-7983

Provider Business Practice Location Address
First Line	:	14701 NW 77TH AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33014-2500
Country	:	US
Telephone Number	:	305-669-2833
Fax Number	:

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

Provider Enumeration Date	:	08/14/2012
Last Update Date	:	08/14/2012

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