Provider Demographics
NPI:1659842615
Name:MAYA GOMEZ, ALEXIS JHONATAN (NP-C)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:JHONATAN
Last Name:MAYA GOMEZ
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 BALTIMORE DR APT 6
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2085
Mailing Address - Country:US
Mailing Address - Phone:760-886-2835
Mailing Address - Fax:
Practice Address - Street 1:5333 BALTIMORE DR APT 6
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2085
Practice Address - Country:US
Practice Address - Phone:760-886-2835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA786796163WM0705X
CA95008246363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical