Basic Information
| Provider Information | |||||||||
| NPI: | 1609208313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15487 BRISTOL CIR W | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337647006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276781247 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2919 W SWANN AVE STE 108 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139302829 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2013 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9107236 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.