Provider Demographics
NPI:1609514397
Name:GOMEZ, BRYAN KRISTOFFER GONZALES
Entity Type:Individual
Prefix:MR
First Name:BRYAN KRISTOFFER
Middle Name:GONZALES
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 1:8613 62ND AVENUE CT SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-5250
Mailing Address - Country:US
Mailing Address - Phone:347-909-8738
Mailing Address - Fax:
Practice Address - Street 1:8613 62ND AVENUE CT SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-5250
Practice Address - Country:US
Practice Address - Phone:347-909-8738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61075740163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse