Provider Demographics
NPI:1659551737
Name:GOMEZ, SUREM SAHARAIM (AAS)
Entity Type:Individual
Prefix:
First Name:SUREM
Middle Name:SAHARAIM
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 HIGHWAY 112
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-6496
Mailing Address - Country:US
Mailing Address - Phone:479-790-7761
Mailing Address - Fax:
Practice Address - Street 1:435 W CENTERTON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-8701
Practice Address - Country:US
Practice Address - Phone:479-795-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2215225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant