Provider Demographics
NPI:1063043164
Name:GOMEZ HERNANDEZ, LUIS MANUEL (APRN)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:MANUEL
Last Name:GOMEZ HERNANDEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8410 W FLAGLER ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2000
Mailing Address - Country:US
Mailing Address - Phone:786-578-3797
Mailing Address - Fax:
Practice Address - Street 1:8410 W FLAGLER ST STE 210
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2000
Practice Address - Country:US
Practice Address - Phone:305-701-1085
Practice Address - Fax:305-701-1086
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005915363LP0808X
FL11005915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107294700Medicaid