Provider Demographics
NPI:1912986068
Name:GOMEZ, DIANA S (FNP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:S
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 W MAGEE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-6439
Mailing Address - Country:US
Mailing Address - Phone:520-498-6467
Mailing Address - Fax:520-531-1424
Practice Address - Street 1:551 W MAGEE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-6439
Practice Address - Country:US
Practice Address - Phone:520-498-6467
Practice Address - Fax:520-531-1424
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN060970363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ330564Medicaid
103685Medicare ID - Type Unspecified
AZ330564Medicaid