Basic Information
Provider Information | |||||||||
NPI: | 1194837146 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOMEZ | ||||||||
FirstName: | SYLVIA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NMW RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 765 MEDICAL CENTER CT STE 209 | ||||||||
Address2: |   | ||||||||
City: | CHULA VISTA | ||||||||
State: | CA | ||||||||
PostalCode: | 919116600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6194278892 | ||||||||
FaxNumber: | 6194227660 | ||||||||
Practice Location | |||||||||
Address1: | 4004 BEYER BLVD | ||||||||
Address2: |   | ||||||||
City: | SAN YSIDRO | ||||||||
State: | CA | ||||||||
PostalCode: | 921732007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6194284463 | ||||||||
FaxNumber: | 6194282625 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 06/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 1570 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   | 163W00000X | 402986 | CA | N |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | FHC18880F | 01 |   | MEDI-CAL | OTHER |