Provider Demographics
NPI:1104595024
Name:GOMEZ, ALBA (PTA)
Entity type:Individual
Prefix:
First Name:ALBA
Middle Name:
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 1:1613 LAVENDER ST
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78541-0221
Mailing Address - Country:US
Mailing Address - Phone:956-219-8105
Mailing Address - Fax:
Practice Address - Street 1:1200 E BUSINESS 83
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-4758
Practice Address - Country:US
Practice Address - Phone:956-601-2274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2162779225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant