Provider Demographics
NPI:1407466774
Name:GOMEZ, CARLOS MANUEL (APRN)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:MANUEL
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5839
Mailing Address - Country:US
Mailing Address - Phone:954-486-4005
Mailing Address - Fax:
Practice Address - Street 1:2010 NW 150TH AVE STE 120
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-2888
Practice Address - Country:US
Practice Address - Phone:954-719-6280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11007700101YM0800X, 363LP0808X
FL11007700363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty