Provider Demographics
NPI:1912156449
Name:GOMEZ, CRISELDA (PA-C)
Entity Type:Individual
Prefix:
First Name:CRISELDA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N BRYAN RD
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-6285
Mailing Address - Country:US
Mailing Address - Phone:956-580-3330
Mailing Address - Fax:956-580-1505
Practice Address - Street 1:611 N BRYAN RD
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-6285
Practice Address - Country:US
Practice Address - Phone:956-580-3303
Practice Address - Fax:956-580-1505
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX333709901Medicaid
TX333709901Medicaid