Provider Demographics
NPI:1205203254
Name:GOMEZ RODRIGUEZ, RACIEL
Entity Type:Individual
Prefix:
First Name:RACIEL
Middle Name:
Last Name:GOMEZ RODRIGUEZ
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 1:4867 GOLDEN GATE PKWY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-6953
Mailing Address - Country:US
Mailing Address - Phone:239-234-5623
Mailing Address - Fax:
Practice Address - Street 1:4867 GOLDEN GATE PKWY
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-6953
Practice Address - Country:US
Practice Address - Phone:239-234-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9403991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily