Basic Information
| Provider Information | |||||||||
| NPI: | 1144473109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | ANA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3860 W OGDEN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606232460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738433000 | ||||||||
| FaxNumber: | 7738432704 | ||||||||
| Practice Location | |||||||||
| Address1: | 3860 W OGDEN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606232460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738433000 | ||||||||
| FaxNumber: | 7738432704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2008 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085003240 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 385002225 | 01 | IL | CS LICENSE | OTHER | 1078264 | 01 | IL | SPECIALTY BOARDS | OTHER | MG1917143 | 01 | IL | DEA | OTHER | 085003240 | 01 | IL | STATE LICENSE | OTHER |