Provider Demographics
NPI:1659095594
Name:GOMEZ, ANDRE JAYLAN (PA)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:JAYLAN
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 NE 2ND ST APT 311
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-2264
Mailing Address - Country:US
Mailing Address - Phone:575-390-4202
Mailing Address - Fax:
Practice Address - Street 1:700 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5004
Practice Address - Country:US
Practice Address - Phone:405-271-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4953207P00000X, 363AM0700X
OKPA4953208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical