Provider Demographics
NPI:1952618316
Name:GOMEZ, MELJUN L (NP-C)
Entity type:Individual
Prefix:
First Name:MELJUN
Middle Name:L
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 W ADAMS ST UNIT 346
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3087
Mailing Address - Country:US
Mailing Address - Phone:773-744-2935
Mailing Address - Fax:773-883-3649
Practice Address - Street 1:2266 N LINCOLN AVE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7600
Practice Address - Country:US
Practice Address - Phone:773-883-3953
Practice Address - Fax:773-883-3649
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008312363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health