Provider Demographics
NPI:1689933210
Name:GOMEZ, NICOLAS SHANE (NAVY DIVE IDC)
Entity Type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:SHANE
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:NAVY DIVE IDC
Other - Prefix:MR
Other - First Name:NICK
Other - Middle Name:SHANE
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NAVY DIVE IDC
Mailing Address - Street 1:2000 W MARINE VIEW DR
Mailing Address - Street 2:BLDG 2202 PSNS/IMF DIVE LOCKER - MEDICAL
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98207-0001
Mailing Address - Country:US
Mailing Address - Phone:425-304-5504
Mailing Address - Fax:
Practice Address - Street 1:2000 W MARINE VIEW DR
Practice Address - Street 2:BLDG 2202 PSNS/IMF DIVE LOCKER - MEDICAL
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98207-0001
Practice Address - Country:US
Practice Address - Phone:425-304-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman