Provider Demographics
NPI:1063625705
Name:GOMEZ, ELIZABETH ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23426 GARRETT AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33954
Mailing Address - Country:US
Mailing Address - Phone:941-764-8296
Mailing Address - Fax:
Practice Address - Street 1:1006 N MILLS AVE
Practice Address - Street 2:DESOTO MEMORIAL HOSPITAL
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266
Practice Address - Country:US
Practice Address - Phone:863-494-5691
Practice Address - Fax:863-494-8167
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 1961225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant