Provider Demographics
NPI:1801904560
Name:GOMES, DOMINIC SUCCOUR (CRNA)
Entity type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:SUCCOUR
Last Name:GOMES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E HARTSDALE AVE
Mailing Address - Street 2:APT 5T
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-2725
Mailing Address - Country:US
Mailing Address - Phone:914-607-2411
Mailing Address - Fax:
Practice Address - Street 1:GRASSLAND ROAD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595
Practice Address - Country:US
Practice Address - Phone:914-493-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY503008367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered