Provider Demographics
NPI:1497329551
Name:GOMEZ, EDGAR R
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:R
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EDGAR
Other - Middle Name:R
Other - Last Name:GOMEZ HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-6365
Mailing Address - Country:US
Mailing Address - Phone:206-543-0903
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-1450
Practice Address - Country:US
Practice Address - Phone:206-543-0903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2023-12-26
Deactivation Date:2023-11-07
Deactivation Code:
Reactivation Date:2023-12-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program