Provider Demographics
NPI:1245716067
Name:GOMEZ, LUIS (ARNP)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 SPRINGLEAF DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-7314
Mailing Address - Country:US
Mailing Address - Phone:305-240-5901
Mailing Address - Fax:
Practice Address - Street 1:1522 SPRINGLEAF DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7314
Practice Address - Country:US
Practice Address - Phone:305-240-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-15
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9203642363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty