Provider Demographics
NPI:1821295734
Name:GOMER, EDWIN D (PA-C)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:D
Last Name:GOMER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 HARBOUR TOWN DR
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1000
Mailing Address - Country:US
Mailing Address - Phone:301-595-0098
Mailing Address - Fax:
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002839363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant