Provider Demographics
NPI:1659969442
Name:GOMEZ, ANDREA CAROLINA (DPT, PT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:CAROLINA
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7844 VALLE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1838
Mailing Address - Country:US
Mailing Address - Phone:909-525-3156
Mailing Address - Fax:
Practice Address - Street 1:10590 TOWN CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0361
Practice Address - Country:US
Practice Address - Phone:909-948-1124
Practice Address - Fax:909-948-1104
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist