MEDICARE: JONATHAN CHRISTIAN GOMEZ IDMT

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	1710I1003X	Independent Duty Medical Technicians

General Provider Information

NPI Number	:	1598190878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN CHRISTIAN GOMEZ IDMT

Provider Business Mailing Address
First Line	:	4311 CARSWELL AVE
Second Line	:	BLDG 340
City	:	LAS VEGAS
State	:	NV
Zip	:	89191-7069
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2444 CASSIDY RD
Second Line	:
City	:	FORT BLISS
State	:	TX
Zip	:	79916-3500
Country	:	US
Telephone Number	:	915-568-8755
Fax Number	:

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

Provider Enumeration Date	:	09/05/2013
Last Update Date	:	03/11/2024

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