Basic Information
| Provider Information | |||||||||
| NPI: | 1750806121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | CARSON | ||||||||
| MiddleName: | CHANELL | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVILA | ||||||||
| OtherFirstName: | CARSON | ||||||||
| OtherMiddleName: | CHANELL | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6346 VILLA DI FIRENZE CT | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891183447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022341461 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3186 S MARYLAND PWKY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029615000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2017 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN002941 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.