Provider Demographics
NPI:1225068851
Name:GOMEZ, KYMBERLY L (PA)
Entity Type:Individual
Prefix:MS
First Name:KYMBERLY
Middle Name:L
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PA
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 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-514-3913
Mailing Address - Fax:314-514-3534
Practice Address - Street 1:14532 S OUTER 40 RD
Practice Address - Street 2:DEPT ORTHOPAEDIC SURG, DEPT STE 200
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5705
Practice Address - Country:US
Practice Address - Phone:314-514-3913
Practice Address - Fax:314-514-3534
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111559363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220054732Medicaid
MO167095OtherBLUE CROSS BLUE SHIELD
MO385480OtherHEALTHLINK
MO000085258Medicare PIN
S36583Medicare UPIN