Provider Demographics
NPI:1417320136
Name:GOMEZ, NICHOLAS (RN)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6613 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3934
Mailing Address - Country:US
Mailing Address - Phone:262-844-7661
Mailing Address - Fax:
Practice Address - Street 1:6613 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53213-3934
Practice Address - Country:US
Practice Address - Phone:262-844-7661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI201815163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse