Provider Demographics
NPI:1356047245
Name:GOMEZ, NICOLAS
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20802
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4105
Mailing Address - Country:US
Mailing Address - Phone:888-402-7256
Mailing Address - Fax:
Practice Address - Street 1:901 45TH STREET,
Practice Address - Street 2:KIMMEL BUILDING
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407
Practice Address - Country:US
Practice Address - Phone:561-844-5255
Practice Address - Fax:561-844-5245
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9119407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant