Provider Demographics
NPI:1871185421
Name:GOMEZ, TIFFANY MADISON ANGELICA (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MADISON ANGELICA
Last Name:GOMEZ
Suffix:
Gender:F
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 1:3701 LEAVITT RD
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-2421
Mailing Address - Country:US
Mailing Address - Phone:440-984-1354
Mailing Address - Fax:
Practice Address - Street 1:6421 SQUIRREL NEST DR
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-4344
Practice Address - Country:US
Practice Address - Phone:440-984-1354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007067RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant