Provider Demographics
NPI:1063043164
Name:GOMEZ HERNANDEZ, LUIS MANUEL (APRN)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:MANUEL
Last Name:GOMEZ HERNANDEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14415 SW 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-3269
Mailing Address - Country:US
Mailing Address - Phone:786-578-3797
Mailing Address - Fax:
Practice Address - Street 1:14400 NW 77TH CT STE 100
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-1590
Practice Address - Country:US
Practice Address - Phone:786-916-6073
Practice Address - Fax:786-657-3092
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11005915363LF0000X
FLAPRN11005915363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107294700Medicaid