Provider Demographics
NPI:1184907560
Name:GOMEZ, VANESSA (ATC, LAT)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19122-6003
Mailing Address - Country:US
Mailing Address - Phone:954-980-5257
Mailing Address - Fax:215-204-2133
Practice Address - Street 1:1801 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-6003
Practice Address - Country:US
Practice Address - Phone:954-980-5257
Practice Address - Fax:215-204-2133
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART005070207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine