Provider Demographics
NPI:1124797048
Name:GOMEZ, EVA H (LPN)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:H
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9401 W GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-1606
Mailing Address - Country:US
Mailing Address - Phone:623-533-3969
Mailing Address - Fax:623-936-0649
Practice Address - Street 1:9401 W GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-1606
Practice Address - Country:US
Practice Address - Phone:623-533-3969
Practice Address - Fax:623-936-0649
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
AZLP049214164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
741589OtherAHCCCS