Provider Demographics
NPI:1598539454
Name:GOMEZ, STASON MICHAEL
Entity Type:Individual
Prefix:
First Name:STASON
Middle Name:MICHAEL
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONTE VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81144-1727
Mailing Address - Country:US
Mailing Address - Phone:719-850-0286
Mailing Address - Fax:
Practice Address - Street 1:301 MONROE ST
Practice Address - Street 2:
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-1727
Practice Address - Country:US
Practice Address - Phone:719-850-0286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COR00153888171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications