Provider Demographics
NPI:1669955613
Name:GOMEZ, JOSEPH MATTHEW (SA-C)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MATTHEW
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 AGUA LADOSO AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-7982
Mailing Address - Country:US
Mailing Address - Phone:575-405-1219
Mailing Address - Fax:
Practice Address - Street 1:7324 SOUTHWEST FWY STE 1550
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-2053
Practice Address - Country:US
Practice Address - Phone:713-779-9800
Practice Address - Fax:832-804-8808
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM16-381246ZC0007X
16-381363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant