Provider Demographics
NPI:1114791712
Name:GOMEZ, MARIE MADELEINE (APRN)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:MADELEINE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 34TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2413
Mailing Address - Country:US
Mailing Address - Phone:434-989-2419
Mailing Address - Fax:
Practice Address - Street 1:2801 PURCELL ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-3551
Practice Address - Country:US
Practice Address - Phone:303-558-0515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
COAPN.0999132363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care