MEDICARE: GUILLERMO GOMEZ NP

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	363LF0000X	Family Nurse Practitioner	RN126015 NP	GA

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	:	1972508752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUILLERMO GOMEZ NP

Provider Business Mailing Address
First Line	:	165 VICTORIA DR
Second Line	:
City	:	ELLENWOOD
State	:	GA
Zip	:	30294-2854
Country	:	US
Telephone Number	:	770-598-2158
Fax Number	:	404-361-2427

Provider Business Practice Location Address
First Line	:	4146 JONESBORO RD
Second Line	:
City	:	FOREST PARK
State	:	GA
Zip	:	30297-1038
Country	:	US
Telephone Number	:	404-361-2469
Fax Number	:

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

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	06/26/2008

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