Provider Demographics
NPI:1609208313
Name:GOMEZ, KRISTINE NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:NICOLE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15487 BRISTOL CIR W
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-7006
Mailing Address - Country:US
Mailing Address - Phone:727-678-1247
Mailing Address - Fax:
Practice Address - Street 1:2919 W SWANN AVE STE 108
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4038
Practice Address - Country:US
Practice Address - Phone:813-930-2829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107236363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical