Provider Demographics
NPI:1023358884
Name:GOMEZ, ROBERT LUCAS (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LUCAS
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3169
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-0169
Mailing Address - Country:US
Mailing Address - Phone:812-237-0211
Mailing Address - Fax:812-237-0182
Practice Address - Street 1:3901 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5709
Practice Address - Country:US
Practice Address - Phone:812-237-0211
Practice Address - Fax:812-237-0182
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99055861A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered