Provider Demographics
NPI:1043562606
Name:GOMEZ, ROGER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:ROGER
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:755 HIGHLAND OAKS DR
Mailing Address - Street 2:STE 202
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-7106
Mailing Address - Country:US
Mailing Address - Phone:336-760-0070
Mailing Address - Fax:336-760-0017
Practice Address - Street 1:755 HIGHLAND OAKS DR
Practice Address - Street 2:STE 202
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7106
Practice Address - Country:US
Practice Address - Phone:336-760-0070
Practice Address - Fax:336-760-0017
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001003771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant