Provider Demographics
NPI:1093481418
Name:GOMEZ, MICHAEL RAY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 W 16TH ST STE P
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6871
Mailing Address - Country:US
Mailing Address - Phone:970-978-4386
Mailing Address - Fax:
Practice Address - Street 1:3400 W 16TH ST STE P
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6871
Practice Address - Country:US
Practice Address - Phone:970-978-4386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPN0335320164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE