Provider Demographics
NPI:1114582681
Name:GOMEZ, JESSICA LIZET (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LIZET
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PA-C
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 4264
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91747-4264
Mailing Address - Country:US
Mailing Address - Phone:626-373-6636
Mailing Address - Fax:
Practice Address - Street 1:4300 ROSE DR
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-2026
Practice Address - Country:US
Practice Address - Phone:714-577-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant