Provider Demographics
NPI:1316593304
Name:GOMES, ALIENA
Entity Type:Individual
Prefix:
First Name:ALIENA
Middle Name:
Last Name:GOMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:8260 GLADIOLUS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4156
Practice Address - Country:US
Practice Address - Phone:239-437-5755
Practice Address - Fax:239-437-5776
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110712100Medicaid