Provider Demographics
NPI:1629505458
Name:GOMEZ, JOSE (PA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:3025 W CHERRY LN STE B
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8531
Mailing Address - Country:US
Mailing Address - Phone:208-302-5350
Mailing Address - Fax:208-302-5325
Practice Address - Street 1:1880 W JUDITH LANE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705
Practice Address - Country:US
Practice Address - Phone:208-302-5350
Practice Address - Fax:208-302-5325
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2019-06-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant